Foodpanda Health and Accident Insurance Claim

Claim Submitted by (Area Manager/Warehouse Incharge's Information)

Name *:

Designation *:

Area/Warehouse Name*:

Mobile Number*:

Email *:

Rider/Picker's Information

Name *:

Rider/Employee ID Number*:

Registered Mobile Number *:

Rider/Picker's NID/Passport/Birth Certificate Number *:

Gender *:

Male Female

Type of health insurance claim

Type of Claim *:

Date of Accident *:

Place Of Accident *:

Hospital Admission Date *:

Hospital Discharge Date *:

Type of OPD Claim

Doctor Visit Only Both Doctor Visit and Diagnostic Test

Payment Information

Payment Mode

Bank Payment Mobile Payment

Account Holder Name *:

Account Number *:

Bank Name *:

Branch Name *:

Bank Routing Number (if available)

Mobile Account Number *:

Please add extra digit in case of Rocket Account

Mobile Account Type*:

bKash Nagad

Medical Documents for Accidental Injury Claim

First Incident Report from the relevant law enforcement authority (if applicable):

Prescription from Doctor/Hospital Emergency ticket*:

All diagnostic reports such as X-ray, CT Scan etc.*:

Bills from Hospital/Medical Practitioner/diagnostic centers *:

Image of the injured part of the body (optional) :

Medical Documents for Hospitalization Claim

Doctor’s Advice for Hospitalization/Emergency Ticket *:

Discharge Certificate *:

Hospital Bills *:

All Diagnostic Reports such as Pathological, Imaging Reports etc. *:

NID/Passport/Birth Certificate*:

Medical Documents for OPD Service Claim

Prescription *:

Prescription from Doctor with Reference for the Test *:

Bill of Diagnostic Tests *:

Diagnostic Test Reports*:

Claimant's Remarks/Comments

I hereby declare that the information and documents provided herein are authentic. I also agree and accept that if the submitted information/documents are incorrect/incomplete/insufficient then the claim settlement may be delayed and submission of unauthentic materials may lead to a claim rejection.

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