Please complete this form in BLOCK letters using blue or black ink. Any unclear instructions will not be performed. Countersign all changes or corrections you make.
Takaful certificate no.
- I/We, the undersigned hereby
- Residing at PO Box no.
- Emirate/City, covered by
- Noor Takaful Certificate no. , herby
- Declare that we have received from the said company the sum of AED representing the amount of indemnity due to me/us in respect of the accident/loss which took place
- DD / MM / YYYY at (time)
- DETAILS OF INDEMNITY
- Being full and final settlement agreed for the repair of TP/participant.
How to Fill Reimbursement form
- Full and complete Medical Report/Diagnosis/Discharge summary.
- from the treating doctor (signed and stamped).
- Original itemized invoices and receipts for the amount claimed.
- with Paid Stamp (invoice must show cost per service).
- Copies of results of diagnostic tests.
- Copies of the prescriptions.
Note: For treatment within UAE, please submit your claim within 60 days from the date of treatment. For treatment
outside UAE, the claim must be submitted within 90 days from the date of treatment.
To be completed by the cardholder
Card holder’s name
Expiry date DD / MM / YYYY Effective date DD / MM / YYYY
To be completed by the treating Physician
Dear Doctor, the beneficiary participating in the medical Takaful
Program is consulting you for medical care and kindly requests you
to complete this form.
Date of onset of symptoms
If hospitalized Date of admission DD / MM / YYYY
Discharge date DD / MM / YYYY
Case management Actual costs