Medical Insurance Form Template

June 23, 2011

Medical insurance form templates are used by the insurance companies to issue medical insurances to the customers and clients. This type of template consists of all the information related to the insurance and the individual concerned.

Sample Medical Insurance Form Template


[Name of the Insurance Company]

[Company Logo]


[Email Address]

[Policy ID Number]: ___________________________________

[Name of agent]: ______________________________________

[Insured’s Name]: _____________________________________

[Effective date of policy]: _______________________________

[Maximum Number of visits per year]: _____________________

Are the following facilities covered? [Manipulation, physical therapy, modalities, medical examination] ________________________________________________________________

Is there a deductible? __________________________________ [Yes / No]

Co – payment or co – insurance: _________________________ [Yes / No]

If yes, then how much: _________________________________________

What is the claims’ address? ___________________________________________________

Secondary Insurance [Details]:

Insured’s Name: ______________________________________

Relation to patient: ____________________________________

Policy Number: _______________________________________

Employer: ___________________________________________

Company Phone: ______________________________________

Financial policy of the company: ________________________________________________

Responsibility of the company: ________________________________________________

Responsibility of the patient: ________________________________________________

Signature of Patient: _____________________________________________

Date: ___________________________

Download Medical Insurance Form Templatee in Word Format



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