Wallet Doctor Claim Application Full Name of Insured (required) Policy Number (required) Patient/Dependent Hospitalised (required) Contact Address Email Address IllnessAccident Date Admitted (required) Time Of Admission (required) BankMobile Admitting Doctor (required) AHFoZ Number Date Discharged Time Discharged Discharging Doctor (required) AHFoZ Number Name of hospital AHFoZ Number Attach Confirmation of hospitalisation from your doctor Attach National ID By submitting this form you accept the Terms & Conditions [recaptcha size:compact]
