{"id":227336,"date":"2021-06-13T22:19:25","date_gmt":"2021-06-13T22:19:25","guid":{"rendered":"http:\/\/sicred.com.al\/raporto-demin-2\/"},"modified":"2025-04-15T11:01:20","modified_gmt":"2025-04-15T11:01:20","slug":"raporto-demin-2","status":"publish","type":"page","link":"https:\/\/sicred.com.al\/en\/raporto-demin-2\/","title":{"rendered":"Report a Claim"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;rgba(0,0,0,0)&#8221; use_background_color_gradient=&#8221;on&#8221; background_image=&#8221;https:\/\/sicred.com.al\/wp-content\/uploads\/2021\/04\/thomas-lefebvre-gp8BLyaTaA0-unsplash-1.jpg&#8221; vertical_offset_tablet=&#8221;0&#8243; horizontal_offset_tablet=&#8221;0&#8243; custom_margin=&#8221;0px|0px|0px|0px|false|false&#8221; custom_padding=&#8221;0px|0px|0px|0px|false|false&#8221; da_disable_devices=&#8221;off|off|off&#8221; 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custom_padding_last_edited=&#8221;on|phone&#8221; header_2_font_size_tablet=&#8221;&#8221; header_2_font_size_phone=&#8221;20px&#8221; header_2_font_size_last_edited=&#8221;on|phone&#8221; z_index_tablet=&#8221;0&#8243; text_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; text_text_shadow_vertical_length_tablet=&#8221;0px&#8221; text_text_shadow_blur_strength_tablet=&#8221;1px&#8221; link_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; link_text_shadow_vertical_length_tablet=&#8221;0px&#8221; link_text_shadow_blur_strength_tablet=&#8221;1px&#8221; ul_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; ul_text_shadow_vertical_length_tablet=&#8221;0px&#8221; ul_text_shadow_blur_strength_tablet=&#8221;1px&#8221; ol_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; ol_text_shadow_vertical_length_tablet=&#8221;0px&#8221; ol_text_shadow_blur_strength_tablet=&#8221;1px&#8221; quote_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; quote_text_shadow_vertical_length_tablet=&#8221;0px&#8221; quote_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_2_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_2_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_2_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_3_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_3_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_3_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_4_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_4_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_4_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_5_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_5_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_5_text_shadow_blur_strength_tablet=&#8221;1px&#8221; header_6_text_shadow_horizontal_length_tablet=&#8221;0px&#8221; header_6_text_shadow_vertical_length_tablet=&#8221;0px&#8221; header_6_text_shadow_blur_strength_tablet=&#8221;1px&#8221; border_color_top=&#8221;#154577&#8243; box_shadow_horizontal_tablet=&#8221;0px&#8221; box_shadow_vertical_tablet=&#8221;0px&#8221; box_shadow_blur_tablet=&#8221;40px&#8221; box_shadow_spread_tablet=&#8221;0px&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2 style=\"text-align: center;\">Report a claim<\/h2>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; da_disable_devices=&#8221;off|off|off&#8221; global_colors_info=&#8221;{}&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_tabs active_tab_background_color=&#8221;#C52B1B&#8221; inactive_tab_background_color=&#8221;#154577&#8243; active_tab_text_color=&#8221;#F7F9FC&#8221; disabled_on=&#8221;off|off|off&#8221; module_class=&#8221;equal-tabs&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; tab_text_color=&#8221;#F7F9FC&#8221; body_font=&#8221;||||||||&#8221; body_font_size=&#8221;15px&#8221; tab_font=&#8221;|300||on|||||&#8221; tab_font_size=&#8221;17px&#8221; custom_padding=&#8221;||||false|false&#8221; hover_enabled=&#8221;0&#8243; border_color_all=&#8221;#e3e5e8&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;][et_pb_tab title=&#8221;CLAIM FORM FOR TRAVEL LIFE AND HEALTH INSURANCE&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; tab_font=&#8221;|300|||||||&#8221; tab_font_size=&#8221;14px&#8221; global_colors_info=&#8221;{}&#8221; tab_font_size__hover_enabled=&#8221;on|desktop&#8221; tab_font_size__hover=&#8221;14px&#8221;]<div class=\"forminator-ui forminator-custom-form forminator-custom-form-246095 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-246095\" data-uid=\"69ec7b6c7c02e\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-246095\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-246095 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"246095\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69ec7b6c7c02e\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ec7b6c7c02e\" id=\"forminator-field-text-1_69ec7b6c7c02e-label\" class=\"forminator-label\">Insurance Policy:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ec7b6c7c02e\" id=\"forminator-field-date-1-picker_69ec7b6c7c02e-label\" class=\"forminator-label\">Inception Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69ec7b6c7c02e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ec7b6c7c02e\" id=\"forminator-field-date-2-picker_69ec7b6c7c02e-label\" class=\"forminator-label\">Maturity Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69ec7b6c7c02e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ec7b6c7c02e\" id=\"forminator-field-textarea-1_69ec7b6c7c02e-label\" class=\"forminator-label\">Please, give detailed description on the circumstances of the insurance event for which you are claiming (Please give details):<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ec7b6c7c02e\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69ec7b6c7c02e\" id=\"forminator-field-date-3-picker_69ec7b6c7c02e-label\" class=\"forminator-label\">Date of occurrence:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69ec7b6c7c02e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ec7b6c7c02e\" id=\"forminator-field-text-2_69ec7b6c7c02e-label\" class=\"forminator-label\">Place of Occurrence:<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69ec7b6c7c02e\" id=\"forminator-field-date-4-picker_69ec7b6c7c02e-label\" class=\"forminator-label\">Date of hospital admission:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69ec7b6c7c02e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69ec7b6c7c02e\" id=\"forminator-field-date-5-picker_69ec7b6c7c02e-label\" class=\"forminator-label\">Date of hospital discharge:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69ec7b6c7c02e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69ec7b6c7c02e\" id=\"forminator-field-text-3_69ec7b6c7c02e-label\" class=\"forminator-label\">Diagnosis:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69ec7b6c7c02e\" id=\"forminator-field-textarea-2_69ec7b6c7c02e-label\" class=\"forminator-label\">The available medical documentation to sustain the authenticity of this insurance case:<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_69ec7b6c7c02e\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69ec7b6c7c02e\" id=\"forminator-field-text-4_69ec7b6c7c02e-label\" class=\"forminator-label\">Claim Amount related to the event for which you are applying:<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ec7b6c7c02e\" id=\"forminator-field-text-5_69ec7b6c7c02e-label\" class=\"forminator-label\">Paid by:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ec7b6c7c02e\" id=\"forminator-field-text-6_69ec7b6c7c02e-label\" class=\"forminator-label\">or; Unpaid:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p style=\"text-align:justify\">This form should be filed by the insured. Only in exceptional cases, when the insured is disabling due to health and\/or physical conditions, the form will be completed by a relative in the presence of the insured or by a person authorized by the relatives of the insured according to the legal provisions in force. In case when the insured has passed away, this form should be filed by the claimant relative\/relatives. For issues and matters not specifically stated in this form, the relevant insurance terms and conditions are applied. SiCRED sh.a. preserves the right to request additional information and documents as well as any other data necessary to estimate this claim.I authorize any physician, hospital employees, hospital, clinic, public or private medical institution, to disclose any information regarding my medical records. I am aware of the general insurance terms and conditions and I am also aware that if I\/we fail to provide the required documents to the Insurance Company, the later has the right to not proceed this claim request and to refuse the claim payment.I declare in my full responsibility that the above given information is true and accurate. If any of the above declarations is found fraudulent, I declare in my full responsibility to waive from this claim request or any other request related to it.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 0.5px solid #aaaaaa;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p><strong>Declarer<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ec7b6c7c02e\" id=\"forminator-field-name-1_69ec7b6c7c02e-label\" class=\"forminator-label\">Name Surname:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69ec7b6c7c02e\" id=\"forminator-field-text-7_69ec7b6c7c02e-label\" class=\"forminator-label\">Residential Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69ec7b6c7c02e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69ec7b6c7c02e\" id=\"forminator-field-email-1_69ec7b6c7c02e-label\" class=\"forminator-label\">Email:<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69ec7b6c7c02e\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ec7b6c7c02e\" id=\"forminator-field-phone-1_69ec7b6c7c02e-label\" class=\"forminator-label\">Phone\/Mob:<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ec7b6c7c02e\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"al\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69ec7b6c7c02e-label\"><label id=\"forminator-field-checkbox-1-1-69ec7b6c7c02e-label\" for=\"forminator-field-checkbox-1-1-69ec7b6c7c02e\" class=\"forminator-checkbox\" title=\"I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69ec7b6c7c02e\" aria-labelledby=\"forminator-field-checkbox-1-1-69ec7b6c7c02e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Disclaimer:<\/label><p style=\"text-align: justify\">SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 \"On personal data protection\" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit submit-but\">D&Euml;RGO<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"4dfe19c0b6\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/227336\" \/><input type=\"hidden\" name=\"form_id\" value=\"246095\"><input type=\"hidden\" name=\"page_id\" value=\"227336\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/sicred.com.al\/en\/raporto-demin-2\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>[\/et_pb_tab][et_pb_tab title=&#8221;CLAIM FORM FOR STUDENT LIFE AND HEALTH INSURANCE&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; tab_font=&#8221;|300|||||||&#8221; tab_font_size=&#8221;14px&#8221; global_colors_info=&#8221;{}&#8221; tab_font_size__hover_enabled=&#8221;on|desktop&#8221; tab_font_size__hover=&#8221;14px&#8221;]<div class=\"forminator-ui forminator-custom-form forminator-custom-form-246102 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-246102\" data-uid=\"69ec7b6c85173\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-246102\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-246102 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"246102\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69ec7b6c85173\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ec7b6c85173\" id=\"forminator-field-text-1_69ec7b6c85173-label\" class=\"forminator-label\">Insurance Policy:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ec7b6c85173\" id=\"forminator-field-date-1-picker_69ec7b6c85173-label\" class=\"forminator-label\">Inception Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69ec7b6c85173\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ec7b6c85173\" id=\"forminator-field-date-2-picker_69ec7b6c85173-label\" class=\"forminator-label\">Maturity Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69ec7b6c85173\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ec7b6c85173\" id=\"forminator-field-textarea-1_69ec7b6c85173-label\" class=\"forminator-label\">Please, give detailed description on the circumstances of the insurance event for which you are claiming (Please give details):<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ec7b6c85173\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69ec7b6c85173\" id=\"forminator-field-date-3-picker_69ec7b6c85173-label\" class=\"forminator-label\">Date of occurrence:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69ec7b6c85173\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ec7b6c85173\" id=\"forminator-field-text-2_69ec7b6c85173-label\" class=\"forminator-label\">Place of Occurrence:<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69ec7b6c85173\" id=\"forminator-field-date-4-picker_69ec7b6c85173-label\" class=\"forminator-label\">Date of hospital admission:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69ec7b6c85173\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69ec7b6c85173\" id=\"forminator-field-date-5-picker_69ec7b6c85173-label\" class=\"forminator-label\">Date of hospital discharge:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69ec7b6c85173\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69ec7b6c85173\" id=\"forminator-field-text-3_69ec7b6c85173-label\" class=\"forminator-label\">Diagnosis:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69ec7b6c85173\" id=\"forminator-field-textarea-2_69ec7b6c85173-label\" class=\"forminator-label\">The available medical documentation to sustain the authenticity of this insurance case:<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_69ec7b6c85173\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69ec7b6c85173\" id=\"forminator-field-text-4_69ec7b6c85173-label\" class=\"forminator-label\">Claim Amount related to the event for which you are applying:<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ec7b6c85173\" id=\"forminator-field-text-5_69ec7b6c85173-label\" class=\"forminator-label\">Paid by:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ec7b6c85173\" id=\"forminator-field-text-6_69ec7b6c85173-label\" class=\"forminator-label\">or; Unpaid:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p style=\"text-align:justify\">This form should be filed by the insured. Only in exceptional cases, when the insured is disabling due to health and\/or physical conditions, the form will be completed by a relative in the presence of the insured or by a person authorized by the relatives of the insured according to the legal provisions in force. In case when the insured has passed away, this form should be filed by the claimant relative\/relatives. For issues and matters not specifically stated in this form, the relevant insurance terms and conditions are applied. SiCRED sh.a. preserves the right to request additional information and documents as well as any other data necessary to estimate this claim.I authorize any physician, hospital employees, hospital, clinic, public or private medical institution, to disclose any information regarding my medical records. I am aware of the general insurance terms and conditions and I am also aware that if I\/we fail to provide the required documents to the Insurance Company, the later has the right to not proceed this claim request and to refuse the claim payment.I declare in my full responsibility that the above given information is true and accurate. If any of the above declarations is found fraudulent, I declare in my full responsibility to waive from this claim request or any other request related to it.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 0.5px solid #aaaaaa;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p><strong>Declarer<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ec7b6c85173\" id=\"forminator-field-name-1_69ec7b6c85173-label\" class=\"forminator-label\">Name Surname:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69ec7b6c85173\" id=\"forminator-field-text-7_69ec7b6c85173-label\" class=\"forminator-label\">Residential Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69ec7b6c85173\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69ec7b6c85173\" id=\"forminator-field-email-1_69ec7b6c85173-label\" class=\"forminator-label\">Email:<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69ec7b6c85173\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ec7b6c85173\" id=\"forminator-field-phone-1_69ec7b6c85173-label\" class=\"forminator-label\">Phone\/Mob:<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ec7b6c85173\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"al\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69ec7b6c85173-label\"><label id=\"forminator-field-checkbox-1-1-69ec7b6c85173-label\" for=\"forminator-field-checkbox-1-1-69ec7b6c85173\" class=\"forminator-checkbox\" title=\"I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69ec7b6c85173\" aria-labelledby=\"forminator-field-checkbox-1-1-69ec7b6c85173-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Disclaimer:<\/label><p style=\"text-align: justify\">SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 \"On personal data protection\" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit submit-but\">D&Euml;RGO<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"8de3a1f138\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/227336\" \/><input type=\"hidden\" name=\"form_id\" value=\"246102\"><input type=\"hidden\" name=\"page_id\" value=\"227336\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/sicred.com.al\/en\/raporto-demin-2\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>[\/et_pb_tab][et_pb_tab title=&#8221;CLAIM FORM FOR LIFE AND ACCIDENTS&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; tab_font=&#8221;|300|||||||&#8221; tab_font_size=&#8221;14px&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; tab_font_size__hover_enabled=&#8221;on|desktop&#8221; tab_font_size__hover=&#8221;14px&#8221; sticky_enabled=&#8221;0&#8243;]<div class=\"forminator-ui forminator-custom-form forminator-custom-form-246109 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-246109\" data-uid=\"69ec7b6c8d146\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-246109\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-246109 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"246109\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69ec7b6c8d146\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><p><strong>Insured Personal Data:<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ec7b6c8d146\" id=\"forminator-field-name-1_69ec7b6c8d146-label\" class=\"forminator-label\">Name, Father, Surname:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-picker_69ec7b6c8d146\" id=\"forminator-field-date-6-picker_69ec7b6c8d146-label\" class=\"forminator-label\">Birthdate:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-6\" value=\"\" placeholder=\"\" id=\"forminator-field-date-6-picker_69ec7b6c8d146\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ec7b6c8d146\" id=\"forminator-field-phone-1_69ec7b6c8d146-label\" class=\"forminator-label\">Mobile no:<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ec7b6c8d146\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"al\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69ec7b6c8d146\" id=\"forminator-field-email-1_69ec7b6c8d146-label\" class=\"forminator-label\">Email:<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69ec7b6c8d146\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69ec7b6c8d146\" id=\"forminator-field-text-7_69ec7b6c8d146-label\" class=\"forminator-label\">Residential Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p><strong>Insurance data:<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ec7b6c8d146\" id=\"forminator-field-text-1_69ec7b6c8d146-label\" class=\"forminator-label\">Insurance Policy Number:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ec7b6c8d146\" id=\"forminator-field-date-1-picker_69ec7b6c8d146-label\" class=\"forminator-label\">Inception date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69ec7b6c8d146\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ec7b6c8d146\" id=\"forminator-field-date-2-picker_69ec7b6c8d146-label\" class=\"forminator-label\">Maturity date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69ec7b6c8d146\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69ec7b6c8d146\" id=\"forminator-field-date-3-picker_69ec7b6c8d146-label\" class=\"forminator-label\">Occurrence date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69ec7b6c8d146\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69ec7b6c8d146\" id=\"forminator-field-text-8_69ec7b6c8d146-label\" class=\"forminator-label\">Medical Center where your received treatment:<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ec7b6c8d146\" id=\"forminator-field-text-2_69ec7b6c8d146-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69ec7b6c8d146\" id=\"forminator-field-date-4-picker_69ec7b6c8d146-label\" class=\"forminator-label\">Date of hospital admission:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69ec7b6c8d146\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69ec7b6c8d146\" id=\"forminator-field-date-5-picker_69ec7b6c8d146-label\" class=\"forminator-label\">Date of hospital discharge:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69ec7b6c8d146\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ec7b6c8d146\" id=\"forminator-field-textarea-1_69ec7b6c8d146-label\" class=\"forminator-label\">Please specify circumstances of the insured event for which you are claiming:<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ec7b6c8d146\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p><strong>Claim Amount related to the event for which you are applying:<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ec7b6c8d146\" id=\"forminator-field-text-5_69ec7b6c8d146-label\" class=\"forminator-label\">Paid by:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ec7b6c8d146\" id=\"forminator-field-text-6_69ec7b6c8d146-label\" class=\"forminator-label\">ose; Pa paguar:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"or; Unpaid:\" id=\"forminator-field-text-6_69ec7b6c8d146\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><p><strong>*All the original supporting documents should be sent via regular mail in the address: <em style=\"text-decoration: underline;text-align: justify\">SiCRED sh.a., Administrative Unit No.5, \u201cBrigada VIII\u201d Str., Building No3\/1, Tirane,&nbsp; Albania<\/em><\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69ec7b6c8d146-label\"><label id=\"forminator-field-checkbox-1-1-69ec7b6c8d146-label\" for=\"forminator-field-checkbox-1-1-69ec7b6c8d146\" class=\"forminator-checkbox\" title=\"Konfirmoj plot\u00ebsimin dhe v\u00ebrtet\u00ebsin\u00eb e informacionit t\u00eb m\u00eb sip\u00ebrm dhe autorizoj SiCRED sh.a. t\u00eb p\u00ebrpunoj\u00eb t\u00eb dh\u00ebnat e mia personale vet\u00ebm p\u00ebr p\u00ebrdorim t\u00eb brendsh\u00ebm t\u00eb SiCRED sh.a.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69ec7b6c8d146\" aria-labelledby=\"forminator-field-checkbox-1-1-69ec7b6c8d146-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Konfirmoj plot\u00ebsimin dhe v\u00ebrtet\u00ebsin\u00eb e informacionit t\u00eb m\u00eb sip\u00ebrm dhe autorizoj SiCRED sh.a. t\u00eb p\u00ebrpunoj\u00eb t\u00eb dh\u00ebnat e mia personale vet\u00ebm p\u00ebr p\u00ebrdorim t\u00eb brendsh\u00ebm t\u00eb SiCRED sh.a.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Disclaimer:<\/label><p>SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 \"On personal data protection\" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit submit-but\">D&Euml;RGO<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"4bf1e6a7a3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/227336\" \/><input type=\"hidden\" name=\"form_id\" value=\"246109\"><input type=\"hidden\" name=\"page_id\" value=\"227336\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/sicred.com.al\/en\/raporto-demin-2\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>[\/et_pb_tab][et_pb_tab title=&#8221;CLAIM FORM FOR LIFE AND HEALTH (CASH PLAN INSURANCE)&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; tab_font=&#8221;|300|||||||&#8221; tab_font_size=&#8221;14px&#8221; global_colors_info=&#8221;{}&#8221; tab_font_size__hover_enabled=&#8221;on|desktop&#8221; tab_font_size__hover=&#8221;14px&#8221;]<\/p>\n[et_pb_section global_module=\"227346\"][\/et_pb_section]\n<p>[\/et_pb_tab][\/et_pb_tabs][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Report a claim<div class=\"forminator-ui forminator-custom-form forminator-custom-form-246095 forminator-design--default  forminator_ajax\" data-forminator-render=\"1\" data-form=\"forminator-module-246095\" data-uid=\"69ec7b6d41b45\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-246095\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-246095 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"1\"\n\t\t\t\tdata-form-id=\"246095\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69ec7b6d41b45\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ec7b6d41b45\" id=\"forminator-field-text-1_69ec7b6d41b45-label\" class=\"forminator-label\">Insurance Policy:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ec7b6d41b45\" id=\"forminator-field-date-1-picker_69ec7b6d41b45-label\" class=\"forminator-label\">Inception Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69ec7b6d41b45\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ec7b6d41b45\" id=\"forminator-field-date-2-picker_69ec7b6d41b45-label\" class=\"forminator-label\">Maturity Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69ec7b6d41b45\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ec7b6d41b45\" id=\"forminator-field-textarea-1_69ec7b6d41b45-label\" class=\"forminator-label\">Please, give detailed description on the circumstances of the insurance event for which you are claiming (Please give details):<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ec7b6d41b45\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69ec7b6d41b45\" id=\"forminator-field-date-3-picker_69ec7b6d41b45-label\" class=\"forminator-label\">Date of occurrence:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69ec7b6d41b45\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ec7b6d41b45\" id=\"forminator-field-text-2_69ec7b6d41b45-label\" class=\"forminator-label\">Place of Occurrence:<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69ec7b6d41b45\" id=\"forminator-field-date-4-picker_69ec7b6d41b45-label\" class=\"forminator-label\">Date of hospital admission:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69ec7b6d41b45\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69ec7b6d41b45\" id=\"forminator-field-date-5-picker_69ec7b6d41b45-label\" class=\"forminator-label\">Date of hospital discharge:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69ec7b6d41b45\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69ec7b6d41b45\" id=\"forminator-field-text-3_69ec7b6d41b45-label\" class=\"forminator-label\">Diagnosis:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69ec7b6d41b45\" id=\"forminator-field-textarea-2_69ec7b6d41b45-label\" class=\"forminator-label\">The available medical documentation to sustain the authenticity of this insurance case:<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_69ec7b6d41b45\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69ec7b6d41b45\" id=\"forminator-field-text-4_69ec7b6d41b45-label\" class=\"forminator-label\">Claim Amount related to the event for which you are applying:<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ec7b6d41b45\" id=\"forminator-field-text-5_69ec7b6d41b45-label\" class=\"forminator-label\">Paid by:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ec7b6d41b45\" id=\"forminator-field-text-6_69ec7b6d41b45-label\" class=\"forminator-label\">or; Unpaid:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p style=\"text-align:justify\">This form should be filed by the insured. Only in exceptional cases, when the insured is disabling due to health and\/or physical conditions, the form will be completed by a relative in the presence of the insured or by a person authorized by the relatives of the insured according to the legal provisions in force. In case when the insured has passed away, this form should be filed by the claimant relative\/relatives. For issues and matters not specifically stated in this form, the relevant insurance terms and conditions are applied. SiCRED sh.a. preserves the right to request additional information and documents as well as any other data necessary to estimate this claim.I authorize any physician, hospital employees, hospital, clinic, public or private medical institution, to disclose any information regarding my medical records. I am aware of the general insurance terms and conditions and I am also aware that if I\/we fail to provide the required documents to the Insurance Company, the later has the right to not proceed this claim request and to refuse the claim payment.I declare in my full responsibility that the above given information is true and accurate. If any of the above declarations is found fraudulent, I declare in my full responsibility to waive from this claim request or any other request related to it.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 0.5px solid #aaaaaa;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p><strong>Declarer<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ec7b6d41b45\" id=\"forminator-field-name-1_69ec7b6d41b45-label\" class=\"forminator-label\">Name Surname:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69ec7b6d41b45\" id=\"forminator-field-text-7_69ec7b6d41b45-label\" class=\"forminator-label\">Residential Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69ec7b6d41b45\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69ec7b6d41b45\" id=\"forminator-field-email-1_69ec7b6d41b45-label\" class=\"forminator-label\">Email:<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69ec7b6d41b45\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ec7b6d41b45\" id=\"forminator-field-phone-1_69ec7b6d41b45-label\" class=\"forminator-label\">Phone\/Mob:<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ec7b6d41b45\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"al\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69ec7b6d41b45-label\"><label id=\"forminator-field-checkbox-1-1-69ec7b6d41b45-label\" for=\"forminator-field-checkbox-1-1-69ec7b6d41b45\" class=\"forminator-checkbox\" title=\"I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69ec7b6d41b45\" aria-labelledby=\"forminator-field-checkbox-1-1-69ec7b6d41b45-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Disclaimer:<\/label><p style=\"text-align: justify\">SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 \"On personal data protection\" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit submit-but\">D&Euml;RGO<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"4dfe19c0b6\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/227336\" \/><input type=\"hidden\" name=\"form_id\" value=\"246095\"><input type=\"hidden\" name=\"page_id\" value=\"227336\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/sicred.com.al\/en\/raporto-demin-2\/\"><input type=\"hidden\" name=\"render_id\" value=\"1\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><div class=\"forminator-ui forminator-custom-form forminator-custom-form-246102 forminator-design--default  forminator_ajax\" data-forminator-render=\"1\" data-form=\"forminator-module-246102\" data-uid=\"69ec7b6d464db\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-246102\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-246102 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"1\"\n\t\t\t\tdata-form-id=\"246102\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69ec7b6d464db\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ec7b6d464db\" id=\"forminator-field-text-1_69ec7b6d464db-label\" class=\"forminator-label\">Insurance Policy:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ec7b6d464db\" id=\"forminator-field-date-1-picker_69ec7b6d464db-label\" class=\"forminator-label\">Inception Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69ec7b6d464db\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ec7b6d464db\" id=\"forminator-field-date-2-picker_69ec7b6d464db-label\" class=\"forminator-label\">Maturity Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69ec7b6d464db\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ec7b6d464db\" id=\"forminator-field-textarea-1_69ec7b6d464db-label\" class=\"forminator-label\">Please, give detailed description on the circumstances of the insurance event for which you are claiming (Please give details):<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ec7b6d464db\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69ec7b6d464db\" id=\"forminator-field-date-3-picker_69ec7b6d464db-label\" class=\"forminator-label\">Date of occurrence:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69ec7b6d464db\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ec7b6d464db\" id=\"forminator-field-text-2_69ec7b6d464db-label\" class=\"forminator-label\">Place of Occurrence:<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69ec7b6d464db\" id=\"forminator-field-date-4-picker_69ec7b6d464db-label\" class=\"forminator-label\">Date of hospital admission:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69ec7b6d464db\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69ec7b6d464db\" id=\"forminator-field-date-5-picker_69ec7b6d464db-label\" class=\"forminator-label\">Date of hospital discharge:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69ec7b6d464db\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69ec7b6d464db\" id=\"forminator-field-text-3_69ec7b6d464db-label\" class=\"forminator-label\">Diagnosis:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69ec7b6d464db\" id=\"forminator-field-textarea-2_69ec7b6d464db-label\" class=\"forminator-label\">The available medical documentation to sustain the authenticity of this insurance case:<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_69ec7b6d464db\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69ec7b6d464db\" id=\"forminator-field-text-4_69ec7b6d464db-label\" class=\"forminator-label\">Claim Amount related to the event for which you are applying:<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ec7b6d464db\" id=\"forminator-field-text-5_69ec7b6d464db-label\" class=\"forminator-label\">Paid by:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ec7b6d464db\" id=\"forminator-field-text-6_69ec7b6d464db-label\" class=\"forminator-label\">or; Unpaid:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p style=\"text-align:justify\">This form should be filed by the insured. Only in exceptional cases, when the insured is disabling due to health and\/or physical conditions, the form will be completed by a relative in the presence of the insured or by a person authorized by the relatives of the insured according to the legal provisions in force. In case when the insured has passed away, this form should be filed by the claimant relative\/relatives. For issues and matters not specifically stated in this form, the relevant insurance terms and conditions are applied. SiCRED sh.a. preserves the right to request additional information and documents as well as any other data necessary to estimate this claim.I authorize any physician, hospital employees, hospital, clinic, public or private medical institution, to disclose any information regarding my medical records. I am aware of the general insurance terms and conditions and I am also aware that if I\/we fail to provide the required documents to the Insurance Company, the later has the right to not proceed this claim request and to refuse the claim payment.I declare in my full responsibility that the above given information is true and accurate. If any of the above declarations is found fraudulent, I declare in my full responsibility to waive from this claim request or any other request related to it.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 0.5px solid #aaaaaa;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p><strong>Declarer<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ec7b6d464db\" id=\"forminator-field-name-1_69ec7b6d464db-label\" class=\"forminator-label\">Name Surname:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69ec7b6d464db\" id=\"forminator-field-text-7_69ec7b6d464db-label\" class=\"forminator-label\">Residential Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69ec7b6d464db\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69ec7b6d464db\" id=\"forminator-field-email-1_69ec7b6d464db-label\" class=\"forminator-label\">Email:<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69ec7b6d464db\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ec7b6d464db\" id=\"forminator-field-phone-1_69ec7b6d464db-label\" class=\"forminator-label\">Phone\/Mob:<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ec7b6d464db\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"al\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69ec7b6d464db-label\"><label id=\"forminator-field-checkbox-1-1-69ec7b6d464db-label\" for=\"forminator-field-checkbox-1-1-69ec7b6d464db\" class=\"forminator-checkbox\" title=\"I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69ec7b6d464db\" aria-labelledby=\"forminator-field-checkbox-1-1-69ec7b6d464db-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I confirm the completion and the accuracy of the above given data and I authorize SiCRED sh.a. to process my personal data for internal use of SiCRED sh.a.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Disclaimer:<\/label><p style=\"text-align: justify\">SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 \"On personal data protection\" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit submit-but\">D&Euml;RGO<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"8de3a1f138\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/227336\" \/><input type=\"hidden\" name=\"form_id\" value=\"246102\"><input type=\"hidden\" name=\"page_id\" value=\"227336\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/sicred.com.al\/en\/raporto-demin-2\/\"><input type=\"hidden\" name=\"render_id\" value=\"1\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><div class=\"forminator-ui forminator-custom-form forminator-custom-form-246109 forminator-design--default  forminator_ajax\" data-forminator-render=\"1\" data-form=\"forminator-module-246109\" data-uid=\"69ec7b6d4bbdb\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-246109\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-246109 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"1\"\n\t\t\t\tdata-form-id=\"246109\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69ec7b6d4bbdb\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><p><strong>Insured Personal Data:<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69ec7b6d4bbdb\" id=\"forminator-field-name-1_69ec7b6d4bbdb-label\" class=\"forminator-label\">Name, Father, Surname:<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-picker_69ec7b6d4bbdb\" id=\"forminator-field-date-6-picker_69ec7b6d4bbdb-label\" class=\"forminator-label\">Birthdate:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-6\" value=\"\" placeholder=\"\" id=\"forminator-field-date-6-picker_69ec7b6d4bbdb\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69ec7b6d4bbdb\" id=\"forminator-field-phone-1_69ec7b6d4bbdb-label\" class=\"forminator-label\">Mobile no:<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69ec7b6d4bbdb\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"disabled\" data-country=\"al\" data-validation=\"international\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69ec7b6d4bbdb\" id=\"forminator-field-email-1_69ec7b6d4bbdb-label\" class=\"forminator-label\">Email:<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69ec7b6d4bbdb\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69ec7b6d4bbdb\" id=\"forminator-field-text-7_69ec7b6d4bbdb-label\" class=\"forminator-label\">Residential Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p><strong>Insurance data:<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69ec7b6d4bbdb\" id=\"forminator-field-text-1_69ec7b6d4bbdb-label\" class=\"forminator-label\">Insurance Policy Number:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69ec7b6d4bbdb\" id=\"forminator-field-date-1-picker_69ec7b6d4bbdb-label\" class=\"forminator-label\">Inception date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69ec7b6d4bbdb\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69ec7b6d4bbdb\" id=\"forminator-field-date-2-picker_69ec7b6d4bbdb-label\" class=\"forminator-label\">Maturity date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69ec7b6d4bbdb\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69ec7b6d4bbdb\" id=\"forminator-field-date-3-picker_69ec7b6d4bbdb-label\" class=\"forminator-label\">Occurrence date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69ec7b6d4bbdb\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69ec7b6d4bbdb\" id=\"forminator-field-text-8_69ec7b6d4bbdb-label\" class=\"forminator-label\">Medical Center where your received treatment:<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69ec7b6d4bbdb\" id=\"forminator-field-text-2_69ec7b6d4bbdb-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69ec7b6d4bbdb\" id=\"forminator-field-date-4-picker_69ec7b6d4bbdb-label\" class=\"forminator-label\">Date of hospital admission:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69ec7b6d4bbdb\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69ec7b6d4bbdb\" id=\"forminator-field-date-5-picker_69ec7b6d4bbdb-label\" class=\"forminator-label\">Date of hospital discharge:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69ec7b6d4bbdb\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69ec7b6d4bbdb\" id=\"forminator-field-textarea-1_69ec7b6d4bbdb-label\" class=\"forminator-label\">Please specify circumstances of the insured event for which you are claiming:<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69ec7b6d4bbdb\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p><strong>Claim Amount related to the event for which you are applying:<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69ec7b6d4bbdb\" id=\"forminator-field-text-5_69ec7b6d4bbdb-label\" class=\"forminator-label\">Paid by:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69ec7b6d4bbdb\" id=\"forminator-field-text-6_69ec7b6d4bbdb-label\" class=\"forminator-label\">ose; Pa paguar:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"or; Unpaid:\" id=\"forminator-field-text-6_69ec7b6d4bbdb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><p><strong>*All the original supporting documents should be sent via regular mail in the address: <em style=\"text-decoration: underline;text-align: justify\">SiCRED sh.a., Administrative Unit No.5, \u201cBrigada VIII\u201d Str., Building No3\/1, Tirane,&nbsp; Albania<\/em><\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69ec7b6d4bbdb-label\"><label id=\"forminator-field-checkbox-1-1-69ec7b6d4bbdb-label\" for=\"forminator-field-checkbox-1-1-69ec7b6d4bbdb\" class=\"forminator-checkbox\" title=\"Konfirmoj plot\u00ebsimin dhe v\u00ebrtet\u00ebsin\u00eb e informacionit t\u00eb m\u00eb sip\u00ebrm dhe autorizoj SiCRED sh.a. t\u00eb p\u00ebrpunoj\u00eb t\u00eb dh\u00ebnat e mia personale vet\u00ebm p\u00ebr p\u00ebrdorim t\u00eb brendsh\u00ebm t\u00eb SiCRED sh.a.\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69ec7b6d4bbdb\" aria-labelledby=\"forminator-field-checkbox-1-1-69ec7b6d4bbdb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Konfirmoj plot\u00ebsimin dhe v\u00ebrtet\u00ebsin\u00eb e informacionit t\u00eb m\u00eb sip\u00ebrm dhe autorizoj SiCRED sh.a. t\u00eb p\u00ebrpunoj\u00eb t\u00eb dh\u00ebnat e mia personale vet\u00ebm p\u00ebr p\u00ebrdorim t\u00eb brendsh\u00ebm t\u00eb SiCRED sh.a.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Disclaimer:<\/label><p>SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 \"On personal data protection\" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit submit-but\">D&Euml;RGO<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"4bf1e6a7a3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/227336\" \/><input type=\"hidden\" name=\"form_id\" value=\"246109\"><input type=\"hidden\" name=\"page_id\" value=\"227336\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/sicred.com.al\/en\/raporto-demin-2\/\"><input type=\"hidden\" name=\"render_id\" value=\"1\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><div class=\"et_pb_row et_pb_row_0\">\n\t\t\t\t<div class=\"et_pb_column et_pb_column_1_3 et_pb_column_0  et_pb_css_mix_blend_mode_passthrough\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_pb_blurb et_pb_blurb_0  et_pb_text_align_left  et_pb_blurb_position_top et_pb_bg_layout_light\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_blurb_content\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"et_pb_blurb_container\">\n\t\t\t\t\t\t<h4 class=\"et_pb_module_header\"><span>Reimbursement form inside SiCRED Medical Network<\/span><\/h4>\n\t\t\t\t\t\t<div class=\"et_pb_blurb_description\"><p>If you have a Life and Health (CASH PLAN) insurance from SiCRED and have received medical services inside SICRED medical network, please fill out the following Form and send it to the given addresses.<\/p>\n<p><a href=\"http:\/\/sicred.com.al\/wp-content\/uploads\/2021\/06\/Reimbursement-Form_inside-SiCRED-Medical-Network.pdf\" rel=\"attachment wp-att-227349\">Vew Form<\/a><\/p><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_column et_pb_column_1_3 et_pb_column_1  et_pb_css_mix_blend_mode_passthrough\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_pb_blurb et_pb_blurb_1  et_pb_text_align_left  et_pb_blurb_position_top et_pb_bg_layout_light\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_blurb_content\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"et_pb_blurb_container\">\n\t\t\t\t\t\t<h4 class=\"et_pb_module_header\"><span>Reimbursement form outside SiCRED Medical Network<\/span><\/h4>\n\t\t\t\t\t\t<div class=\"et_pb_blurb_description\"><p>If you have a Life and Health (CASH PLAN) insurance from SiCRED and have received medical services outside SiCRED medical network or for medical services received without prior authorization from SiCRED, please fill out the following Form and send it to the given addresses.<\/p>\n<p><a href=\"http:\/\/sicred.com.al\/wp-content\/uploads\/2021\/06\/Reimbursement-Form_outside-SiCRED-Medical-Network.pdf\" rel=\"attachment wp-att-227351\">Vew Form<\/a><\/p><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_column et_pb_column_1_3 et_pb_column_2  et_pb_css_mix_blend_mode_passthrough et-last-child\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_pb_blurb et_pb_blurb_2  et_pb_text_align_left  et_pb_blurb_position_top et_pb_bg_layout_light\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_blurb_content\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"et_pb_blurb_container\">\n\t\t\t\t\t\t<h4 class=\"et_pb_module_header\"><span>Prior Authorization Form<\/span><\/h4>\n\t\t\t\t\t\t<div class=\"et_pb_blurb_description\"><p>If you have a Life and Health (CASH PLAN) insurance from SiCRED and need to receive medical services which require prior authorization from SiCRED, please fill out the following Form and send it to the given addresses.<\/p>\n<p><a href=\"http:\/\/sicred.com.al\/wp-content\/uploads\/2021\/06\/KERKESE-PER-AUTORIZIM-PARAPRAK.pdf\" rel=\"attachment wp-att-227316\">Vew Form<\/a><\/p><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","inline_featured_image":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-227336","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/pages\/227336","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/comments?post=227336"}],"version-history":[{"count":13,"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/pages\/227336\/revisions"}],"predecessor-version":[{"id":246110,"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/pages\/227336\/revisions\/246110"}],"wp:attachment":[{"href":"https:\/\/sicred.com.al\/en\/wp-json\/wp\/v2\/media?parent=227336"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}