Insurance Claims | Fidelity
Insurance Claims (ACS Beirut)
Full Name
*
ACS ID
*
ACS E-mail
*
Example@acs.edu.lb
Applying For
*
Please Select
Myself
An Insured Dependent Family Member
Who are you applying for?
Are you registered with the NSSF?
*
Please Select
Yes
No
NSSF Number
*
Insured Dependent's Full Name
*
Is your insured dependent family member registered with the NSSF?
*
Please Select
Yes
No
NSSF Number (Insured Dependent)
*
Insurance Card Number
*
Check the front side of your Insurance Card.
Claim Type / Category
*
Please Select
Doctor Visit + Medicine
Doctor Visit + Vaccination
Doctor Visit
Hospital
Medicine
Tests
Vaccination
Other
Please Specify
*
Claim Date
*
-
Day
-
Month
Year
Claim Total LL Amount (Lebanese Lira - LL)
Claim Total USD Amount (US Dollar - $)
Currency
*
Please Select
L.L.
$
Files / Documents Upload (1)
*
Browse Files
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Choose a file
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of
Files / Documents Upload (2)
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Files / Documents Upload (3)
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Files / Documents Upload (4)
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