GNP~ Grupo Nacional Provincial, S.A.Av. Cerro de las Torres 395, Col. Campestre ChurubuscoC.P. 04200, Mexico, D.F. Tel: 52273999www.gnp.com.mx

Medical ExpensesSEGUROS

Medical Report

The treating physician must complete this form in block capitals and sign it. Please do not leave any blank spaces. This

document will not be valid if it has anv d~l~tion or erasure and no subseCluent chanaes will be accepted.'.1 '.':1;:1;"'.

o Refunds

Patient's NamePaternal Surname

Date of birthMaternal Surname

I

Name(s) Month Day Year

Sex

OM

Age PolicyNo. Reason tor treatment

OF o Pregnancy o IlIness o Accident

Personal pathological background Personal non-pathological record

Gynecological-obstetic record Perinatal record (if necessary)

Pie ase specify the date on which the condition based on the clinical record and natural evolution of the iIIness Start Date

Month Day Year

ICO Code Final diagnosi~ Diagnosis Date

Month Day Year

Have you suffered from any other condition?

O Ves O No Which?I

Result of physical examination and studies carriep out (attach interpretations that confirm diagnosis)

O Acquired O ChronicO Congenital O Acute

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/./ .... (',

,. '/// .',\"..."...... ,...

CPT4 for reference only Description o treatment Start DateMonth Day Year

I I

Complications? Description of complic¡¡¡tionsOYesO No

Additionalinformation I

(J.i¡mgI. ...,YrY.', ljW'((y,(u' u/u(Y..( Ir$tate

Type of stay Dateof AdmissionMonth Day Year

O Emergency O Hospital O Short/ ambulatorystayI I

1/liJet811$ .:.J",...¡ /III '''! .'" -

Paternal Surname

Materna'iurname

Name(s) Type 01 involvement

Speciality

I Prolessio'al Licence I SpecialtyLicenseor Certification

Quotation

Telephone number

I Mobiletelephonenum¡er I Fax number I Pager I E-mail (il any)Paternal Surname

Materna'iurname

Name(s) Type 01 involvement

Speciality

I prolessiOra,Licence I SpecialtyLicenseor Certification

Quotation

Paternal Surname

Materna'iurname

Name(s) Type 01 involvement

Speciality

I proleSSiOra, Licence I Specialty License or Certilication

Quotation

I hereby inlorm the insurance company that all inlormatifm included on this lorm coincides with the medical records 01which I am aware due to relerences made by thepatient or members 01 his or her lamily, or through the s udies that I have carried out under my own strictest liability.

Place and date

Name and signature of treating physician

Grupo Nacional Provincial, S.A.Av.CerrodelasTorres395,Col.CampestreChurubuscoC.P.04200, Mexico, D.F. Tel: 5227 3999www.gnp.com.mx

Notification of accident or il!neSS(Refund, programming of s~rvices and/or medical treatmenfThis form must be completed with correct and detailed information, and be signed by the

Insured. Submission of this form does not m~an that the Company is required to admit thevalidity of the claim, nor waive the rights reserved under the policy. This document shall notbe valid if it has anv deletion and/or erasure. I

GNpeSEGUR.OS

Paternal Surname Name(s)

Unique citizen's registration number (if any)Tax#

Marital status -lOS DM DD DW DCDoes the Insured party or has the Insured Party hela any positionin the state or federal government the last four year~?

Private Address iStreet

OYesO No

Position

Precinct

Municipality or District CountryCity or Town

Paternal Surname

Occupation Relation with policy holderTax#

Precinct

Municipality or District State Country

111.Details \>fthe contractinPaternal Surname

Tax#

Does the Insured party or has the Insured Party helClany positionin the state or federal government the last four year~?

OYesONo

Position

Corporate Name

Une of business or corporate purpose

Tax#

MaternalSurname

Address of contractinStreet

individual 01' comDanart

Precinct

Municipality or Delegation City orTown State Country

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MedicalExpenses

year

Municipality or District

National~y (otherthan Mexican)

applicant

Name(s)

Asistencia Línea Azul

We can IproVide you the following benefits 24 hours a day, 365 days ayear. 1dvice regarding how the policy works. I~formation on physicians who are associates of the Medical Circleo.. 1ree medical advice over the telephone, provided by Medica Movil. Irformation regarding associate hospitals.Irformation regarding medical supplies that offer preferential rates.'

f

formation on the processing of your claim.

5227 3333 Mexico City01 800001 9200 TolI Free National

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Have you previously claimed expenses lor this condition with this or another company?

I ClaimNumberI

Type 01claim O First O Complementary

ForI

I Specilythe diagnosison whichyourclaimwas basedO Accident O IlIness O Pregnanpy

1Iaccident, please specily how and when it occurred Date 01accident orbeginning 01 condition

I

I

month I day I yearI

In the event 01 a traffic accident, I Name 01the CompanyI Coverage Ilnsured Sum I Policy Number

OYes ONowas the vehicle insured? I

Atlach a copy 01the police report or prool and/or th report Irom the Company, and the interpretation 01studies made.

Hospital to which you were admitled II Details01programmedadmission

time monthI day I yearI I

Physician'sName II Specialty I Does the hospitalhave an agreementwith the Company?I OYes IO No

Throughwhich mediumwas your physicianrelereed?

O GNP Seguros O Hospital IO Other

I herebydeclarethat all inlormationincludedon thisldocumentis true andthat it coincideswith the medicalrecord01which I am aware andthat I shall be liablelor anyconsequences.I

I Name andsignature01the InsuredPartyand/orPolicyHolder

II

GNp$: Grupo Nacional Provincial, S.A.

Av. Cerro de las Torres 395, Col. Campestre ChurubuscoC.P. 04200, Mexico, D.F. Tel: 5227 3999 www.gnp.com.mxSEGUROS

Refund of accident and/or il~nessPlease submit this form with your original eXPlensereceipts.

This form shall not be valid if it has any deleti\>n or amendment.

Polieyear

Paternal Surname

Condition

Customer Code or Certifieate Number

Paternal Surname

Relationship with poliey holder

II an additional payment, note thenumber 01the first elaim related to

the treatment in question

Name or eompany name

Deseription

1. Extra-hospital expenses(medieation, analyses, X rays, studies, ete.)

Amount 01expenses elaimed

2. Medieal lees lor doctors' appointments

3. Hospitalization expenses

4. Medieal lees lor surgery(Fees or surgeon, assistant and anaesthetist)

5. Other (speeily)

Note: The total amount of expenses claimed mu~t agree exactly with the total of thereceipts provided, and reeeipts should be submltted in the same order as the items listed.

i

Total

Munieipality or District Town and/or State

year

and iIIness only

Signature of the Insured

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IImportant Note: We recommend that you r~ad the conditions or your contract before making a claim, as it includes certain exclusions andlimitations. Ifyou have any doubts, please contact your insurancebroker.

Please check that your documents meet the followingrequirements, so that we may process your claim more quickly and efficiently.

1. Please send the followingdocuments: 5. When you buy your medication at the drugstore, attach thea) Accident and/or IIIness Refund Fqrm receipt and the physician's prescription. Cross out anyb) Notificationof Accident or IIlness and Medical Report medication or articles that are not for the patient.c) Receipts of expenses that meet tax requirementsd) Copy of fullclinical recorde) Interpretation of studies and copy of studies carried out.

6. Physicians must raise a receipt for their fee for eachappointment. The amount of the fee, noted on the prescription,shall not be va lid for payment for your claim.

Check that when the hospital and the physician raise the totalaccount, they itemize the cost for each item of which it is a part(daily rental of room, medical fees, appointments, anaesthetist,etc.)

2. The physician that treats you must Iproperly complete theMedical Report, paying particular attention to the diagnosisgiven and the dates requested.

Original expense receipts must be submitted for review(itemized hospital invoice, receipts of physicians andassistants, drugstore receipts attached to prescription, etc.).Receipts for fees must be signed by the person who issuesthem; facsimiles shall not be accepted.

7.

3.

8. payments to charity organizationsestablishmentsshall not be accepted.

If two claims are submitted at the same time, separate theexpenses for each accident and/or iIIness and completeseparatedocumentsfor each claim.

or official service

9.4. Receipts for the professional fees of physicians, assistants and

anaesthetists must be raised using the forms established bythe Treasury Department, and be made out to the PolicyHolder. Said receipts must specify theldescription of the itempaid for, for example, appointment, assistance, etc.

10. AII receipts must be requested in the name of the PolicyHolder.

Remember:

Programming! your surgery or medical treatment will provide you major benefits.

Make the most of itl!!