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FORMULARIO DE RECLAMACIÓN PARA ACCIDENTES PERSONALES A CONSECUE
FORMULARIO DE RECLAMACIÓN PARA ACCIDENTES PERSONALES A CONSECUENCIA DE UN ACCIDENE DE TRANSITO
UN FORMULARIO POR CADA PERSONA LESIONADA
UN FORMULARIO POR CADA PERSONA LESIONADA
IMPORTANTE: Para evitar demoras innecesarias en el proceso de s
IMPORTANTE: Para evitar demoras innecesarias en el proceso de su reclamo conteste todas las preguntas detalladamente:
SECCIÓN “A” PARA SER COMPLETADA POR EL RECLAMANTE
SECCIÓN “A” PARA SER COMPLETADA POR EL RECLAMANTE
RECLAMO No. Nombre del Asegurado
RECLAMO No. Nombre del Asegurado: Vehículo en que viajaba: Nombre del reclamante: Número de DPI: Edad: Sexo: M ( ) F ( ) Fecha de nacimiento: Estado Civil: Ocupación:
Médicos que prestaron sus servicios:
Médicos que prestaron sus servicios:
Nombre: Dir
Nombre: Dirección: Teléfono:
TIENE SEGURO DE GASTOS MÉDICOS O ACCIDENTES PERSONALES:
TIENE SEGURO DE GASTOS MÉDICOS O ACCIDENTES PERSONALES: SI ( ) NO ( ) Si su respuesta es afirmativa, favor indicar nombre y número de póliza. Por este medio certifico que las respuestas que anteceden y las facturas adjuntas son verídicas y cabales, según mi leal saber y entender. Autorizo a todos los médicos y otras personas que me atendieron y a todos los hospitales y otras instituciones para que suministren a la Compañía de seguros que ampara la presente póliza, cualquier información incluyendo copias exactas de sus archivos, exámenes de laboratorio y rayos X pertenecientes a este reclamo. Queda entendido que la Compañía se reserva el derecho de aplazar la liquidación de este reclamo, hasta la obtención de todas las pruebas necesarias para la misma a su completa satisfacción.
Fecha:
Fecha: Firma: Dirección: Teléfono:
NO OLVIDE ADJUNTAR LAS FACTURAS DETALLADAS DE LOS GASTOS DE HOS
NO OLVIDE ADJUNTAR LAS FACTURAS DETALLADAS DE LOS GASTOS DE HOSPITAL, DE TODOS Y CADA UNO DE LOS PROFESIONALES QUE INTERVINIERON EN EL CASO (CIRUJANOS, RADIOLOGO, LABORATORISTA, RESULTADOS DE LABORATORIO, MEDICINAS, RECETAS Y RX)
SECCIÓN “B” PARA SER COMPLETADA POR EL MÉDICO TRATANTE
SECCIÓN “B” PARA SER COMPLETADA POR EL MÉDICO TRATANTE
Favor completar todas y cada una de las preguntas con el mismo
Favor completar todas y cada una de las preguntas con el mismo tipo de letra.
1. Nombre del Paciente:
1. Nombre del Paciente: Edad: Sexo: M ( ) F ( ) 2. Fecha de la primera consulta por esta incapacidad: 3. De su diagnóstico completo: 4. Según su opinión, cuando se originó la causa básica de esta lesión: 5. Fecha inicial del tratamiento: 6. Ordenó usted hospitalización: SI ( ) NO ( ) En caso negativo nombre del médico que la ordenó: Dirección: Teléfono: 7. Si el paciente fue referido por otro médico o hay otro médico involucrado favor citar: Nombre: Dirección: Teléfono:
Continua en la parte Posterior
Continua en la parte Posterior
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