# Invoice No. Ins. Company Claim Submission Date Claim Note Claimed Amt.(฿)
01 NSB7881 Aviva 26-03-2020
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
562.10 attach_file Attach Docs.
02 BC65243 TATA AIA 27-03-2020
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
747.29
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...
03 IN32456 Aviva 31-03-2020 9000.00
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...
Income Type Catalog
Price (฿)		 Billable
Amount (฿)		 Claimed
Amount (฿)
1.1 Hospital Medical Expenses 3000.00 2700.00 2000.00
1.2 Health Professional Fees 2000.00 1800.00 1500.00
1.1.1 Drugs and Parenteral Nutrition 5000.00 4500.00 3000.00
1.1.3 Blood Transfusion Services and Blood Com... 1500.00 1350.00 500.00
1.1.5 Drugs and Parenteral Nutrition 2500.00 2250.00 2000.00
Total 14,000.00 12,600.00 9,000.00
04 BC32456 TATA AIA 31-03-2020 Add Note 766.71
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...
Attach Docs.
05 BC32456 TATA AIA 04-04-2020
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
544.83
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...

Doctor Form

arrow_drop_up