Reimbursment Claim Form - Resolution Insurance
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1REIMBURSMENT CLAIM FORM
Claim Ref. No.
HEAD OFFICE: Parkfield Place, Muthangari Drive, Off Waiyaki Way, Westlands
1. Patient Must Complete Section A, B and D
P. O. Box 4469 - 00100, Nairobi, Kenya | Tel: +254-20-2894 000
2. The Attending Doctor Must Complete Section C
Mobile: +254-709-990 000, +254-730-199 000
3. Claims Should Be Submitted Within 30 Days
Pre-Authorization Tel: +254 20 2894 222, +254 720 756 000, +254 734 828 812
Email: care@resolution.co.ke
A. PERSONAL DETAILS
First Name
Middle Name
Last Name
Name of Patient:
Membership Number
D.O.B:
D
D
M
M
Y
Y
First Name
Middle Name
Last Name
Name of Principal Member:
Company Name
Principal Member’s Employer:
B. DETAILS OF ILLNESS
Date of first onset of symptoms:
D
D
M
M
Y
Y
Date of first consultation with doctor:
D
D
M
M
Y
Y
DECLARATION
I hereby declare the above statements to be true and complete. I also consent to Resolution Insurance Company Limited seeking further information from any
medical institution or doctor whom my dependants or I have consulted.
Date:
Signed:
Member / Guardian
D
D
M
M
Y
Y
C. DIAGNOSIS
Doctor’s Name:
Date:
D
D
M
M
Y
Y
Sign & Stamp:
D. BANK DETAILS (Indicate the principal member account details)
First Name
Middle Name
Last Name
Account Holder’s Name:
Bank Name:
Branch:
Account Number:
Account Holder’s Relation to the Claimant:
E. REIMBURSEMENT CHECKLIST
The following are Mandatory for prompt claims settlement:
Original Payment Receipts
Itemized Bill
Duly signed and stamped Medical Report / Discharge Summary (for Inpatient ONLY)
Bank Details
Narration (if treated by provider on the RIL panel)
Kindly contact me for the refund on Telephone:
Email:
NB: A duly filled reimbursement claim form with all mandatory documents should be submitted to the claims department within 30 days.
RI/MC/FM/29 Rev.0
January 2017
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Parent category: Medical