
Claims Data - itemized to single claims

by MIBAV Service

Through this information we can negotiate the future costs more precisely.

Client (HQ) *

Legal Entity (LE) *

Country *

Insurer *

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- The claims data belong to the client. Therefore the insurer must guarantee that these data are correct. -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Coverage *

Year *

Claims - ID-Code *

Claim - Status *

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Claimant -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Claimant *

Date of birth *

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Basis Data on the Claim -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Claim - Date *

Date of Reporting *

Date of Admission *

Date of Closure

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Description of this Claim -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Location of Claim *

Location of Treatment (Health)

Description *

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Financial Projections -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Amount expected

Waiting Period *

Underwriting Year *

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Payments -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Benefits - Start

Benefits - End

Benefits - Frequency *

Amount paid - reference period

Amount paid - TOTAL

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Reserves -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Claim Reserves

OSLR - at begin

OSLR - at end

Other Reserves

Notes

Comments

----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Signature -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

Filled out by *

Position

EMail

Date *

Please enter the characters you see

Claims Data - itemized to single claims

by MIBAV Service

Through this information we can negotiate the future costs more precisely.