Policy No.: Claim No.

(Hereinafter called Tata AIA or the Company, whichever is applicable) HOSPITALIZATION CLAIM FORM
Office ___________________________________ Agency _______________ Code ______________ Agent _______________ Code ______________

Tata AIA Life Insurance Company Limited

PART I (To be completed by Insured/Claimant in BLOCK letters) Please answer all questions, use not applicable (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form. The filing of this claim form is not to be construed as an admission of liabilities of our Company. No agent has been or is authorized to admit any liabilities on behalf of the Company.

(Note: - Insureds name should be written in full as the same will appear on the cheque) Policy No. Full Name of Insured Alias, if any Benefits to Claim: (please tick) Daily Hospital Benefit Insureds Address Contact Phone No. Bank Account No. Payment Method (tick the option) CHEQUE NEFT Post-Hospitalization Benefit

Age Sex

Surgical Benefit I. D. No.

Dismemberment

I. D. Document Type

Advance Discharge Voucher submitted - YES Occupation & exact duties Employer Name & Address

Contact Phone No. Are you claiming from other insurers or institutions (including government/welfare schemes) for the same cause? Yes, for (type & amount) _______________________________ _______________________________ Did a medical leave certificate filed to Insureds employer? Claims Details Describe initial symptoms / parts of body injured from ___________________________________ from ___________________________________ Yes, (state the dates) __________________ No No

Since when does the Insured have these symptoms / bodily injury Date of first consultation
MM DD MM DD YYYY

YYYY

Diagnosis given by doctor Is the condition due to an accident? Accident Date Accident Details
MM DD YYYY

The first doctor consulted (name, address & telephone) No. Yes, details below: Time (am / pm) Place

Consultation Details a) Insureds regular doctor b) All other doctors consulted for this illness/injury; or similar condition in the past

Name, Address & Telephone

Consultation Dates

Disease / Condition

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 5647 9000. Fax No.: - 022 5502 4123. Registered Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

c)

Doctor who referred Insured to hospital

Please give details of any other illness Insured have suffered from in the past. Disease/Condition Consultation Dates Doctor consulted (Name, Address & Telephone No.)

Hospitalization Details Details of hospital confinement for the injury/illness. Name of Hospital Address Date of consultation(s) Date & time of admission Date & time of discharge

Any surgical procedure(s) done during hospitalization? No Yes, details:

Information of Claimant (if other than the Life Insured) [Note:- Claimant name should be written in full as the same will appear on the cheque] Name in Full ID No. ID Type Sex: Male Female Address Relationship with the Insured

Age

Telephone No. In what title are you submitting this claim?

Bank Account no. (tick the option)

Advance Discharge Voucher submitted - YES

Payment Method -

CHEQUE

NEFT

I/We hereby declare that the information given on this accident/hospitalization claim application form is true and complete. /We hereby make claim to Tata AIA by submitting this accident/hospitalization claim application form and agree that the written statements of all the physicians who attended or treated the Insured and all other proofs and supporting documents associated with this accident/hospitalization claim application form shall constitute and are hereby made part of this accident/hospitalization claim application form. I/We further agree that the furnishing of this accident/hospitalization claim application form, or of any other forms supplemental hereto by the Company, shall not be deemed an admission of an existence of any assurance in force on the life in question, nor an admission of liabilities or a waiver of any of its rights of defenses. I/We hereby declare and agree that any personal information collected or held by the Company (whether contained in this application or otherwise obtained) is provided and may be held, used, and disclosed by the Company to individuals/organizations associated with the Company or any selected third party (within or outside of India, including reinsurance and claims investigation companies and industry associations/federations) for the purposes of processing this application and providing subsequent services for this and other financial products and services, direct marketing, and data matching, and to communicate with me/us for such purposes. I/We hereby irrevocably authorize: (i) any organization, institution, or individual that has any record or knowledge of my/the Insureds health and medical history or any treatment or advice and that has been or may hereafter be consulted, other personal information or details of related accident/injury to disclose to the Company such information; (ii) the Company and its approved medical examiners and laboratories to perform medical assessment and tests to evaluate Insureds health condition, or to perform any autopsy as appropriate.

DECLARATION AND AUTHORIZATION

This authorization shall bind my/the Insureds successors and assigns and remain valid notwithstanding my/the Insureds heath or incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as the original.
Witness Signature ___________________________ Name of the Witness _________________________ (in block letters, family name first) Address of Witness: _____________________________ Designation: ____________________ Claimant Signature _______________________ Date ___________________________________ Name of Claimant _________________________

Note: Witness should be notary / Gazetted officer / SEM or a person of local standing.
\

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 5647 9000. Fax No.: - 022 5502 4123. Registered Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

Policy No.: Claim No.:

(Hereinafter called Tata AIA or the Company, whichever is applicable) CERTIFICATE OF MEDICAL ATTENDANT
To be completed in BLOCK letters by a duly qualified and registered medical practitioner at the claimants expense. Please answer all questions, use not applicable (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form. Patient Name Patients Occupation Patients Address Age I. D. No. I. D. Document Type Sex

Tata AIA Life Insurance Company Limited

Consultation Details
If due to ILLNESS, please provide: Chief complaints & presenting symptoms If due to ACCIDENT, please provide: Conditions of injury & parts of body involved

Is there external visible evidence of injury at your first consultation: If yes, give details Date symptoms first appeared Your Diagnosis Date of your consultation of this illness/injury First consultation on Last consultation on Past medical history, family history and co-morbid conditions (please give consultation dates & details) Date of injury Cause of injury

Hospitalization Details
Hospital Name Address

Does this illness/injury necessitate inpatient hospitalization:

No

Yes, details as below:Date & Time of Admission Date & Time of Discharge

Any surgical procedure performed? Date of operation Name of surgical procedure Tests & investigations performed? Name of test/investigations

No

Yes, details as below:Place of operations Surgeon Name & Registration No.

No

Yes, details as below:Date(s) Results (please enclose a certified true copy of the test results)

Other treatments administered (medicines, dressing & suturing etc) Discharge summary & treatment plan Dates of follow-up consultations with you after hospital discharge for the same illness/injury Date(s) Condition

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 5647 9000. Fax No.: - 022 5502 4123. Registered Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

Was healing complicated? If yes, state reasons and any special treatment given. Bearing in mind the patients occupation, do you feel the illness/injury would have prevented him/her from working at your first consultation at your last consultation If absence from work more than 2 weeks was necessary, please state the reasons. Is the illness/injury related to (a) Physical defects/congenital anomaly (b) Unfavourable past medical history (c) Degenerative changes (d) Alcohol, drug, or nicotine/smoking (e) AIDS or HIV infection (f) Suicide or self-inflicted injury Other doctors/hospitals involved in the care of the patient Name Address

No

Yes, details as below:-

No No

Yes, details: _______________________________ Yes, details: _______________________________

No No No No No No

Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Telephone No.

Declaration by the Attending Physician/Specialist I declare that the answers given are true and complete. I declare I am duly licensed and registered to practice western medicine (allopathy) in India (if outside India, please state where ______ ) Certification by Hospital Admitted, that 1) The Hospital is duly licensed and registered as a Hospital to provide treatment in western medicine (allopathy) in India (if outside India, state where ___________) for the care and treatment of sick and injured persons as registered in-patients, fully equipped with facilities for diagnosis and major surgery which are under the constant supervision of one or more Registered Medical Practitioners, and which have 24-hour a day full time professional nursing services; And Maintains proper medical and patient records and quality health care to the standards as required under the prevailing laws and regulations in the geographical area it is located; And Is not an institution operated as a convalescent or rest home, a hotel, a home for the aged, a place for alcoholics or drug addicts, or Custodial Care, or for any similar purpose. The Hospital has on the following facility and resource (please state) No. of in-patient beds : ___________________ No. of qualified registered resident doctors: ___________________ No. of qualified registered full time nurses : ___________________ ___________________________________________________ Signature of authorized Hospital Administrator

2) 3) 4)

__________________________________________________ Signature of Attending Physician/Specialist (with qualifications) [Name in Block: ]

[Name in Block:

_____________________________________________
Registration No. & Place __________________________________________________ Address & Official Stamp __________________________________________________ Telephone __________________________________________________ Mobile No. __________________________________________________ Email Address ___________________________________________________ Date

Name of Hospital

_____________________________________________

___________________________________________________ Registration No. & Place ___________________________________________________ Address & Official Stamp __________________________ Telephone _______________________ Fax No.

___________________________________________________ Email Address ___________________________________________________ Date

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 5647 9000. Fax No.: - 022 5502 4123. Registered Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

Please provide your answers in the right column and return it to us at the following address for our database: Tata AIA Life Insurance Co. Ltd. 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Attn: Claims Department Name of hospital : Registration no. & Registering authority & Place : Address : Tel. No. : Fax no. : Web site : Name of contact person : Designation : Telephone no. : Email address : Name of Owner (if different from contact person above) : The Hospital provide treatment in (tick as appropriate) : Specialties available (e.g. Paediatrics, Orthopaedics, ENT etc) If yes, please state details: No. of in-patient beds: No. of qualified registered resident doctors : For government hospitals, please also state No. of Professor doctors: No. of Assistant Professor doctors: No. of Lecturer doctors: No. of qualified registered full time nurses : In House facility available [please state Yes in the right column if available] Pathology Lab. : Oxygen : Central supply : Cylinder : western medicines (allopathy) alternate medicines (state details) ________________________

Hospital Information Sheet

E. C. G. : X Ray : Ultrasonography : C. T. Scan : M. R. I. Scan : CLM/P4.9/4.T3 (III) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 5647 9000. Fax No.: - 022 5502 4123. Registered Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai 400 013

Pathology : Blood Bank : Operation Theatre : Labour room / delivery room : I. C. C. U.: Cardiac monitor : Defibrillator : Ventilator : Emergency Room : Day Care Centre : Outpatient consultation : Computerized access to patient records : Other facilities please state details :

The above information is certified to be true and complete.

__________________________________________________________________ Signature of Hospital Administrator [Name in Block: __________________________________________________________________ Hospital Name & Official Stamp ]

______________________________________ Date

CLM/P4.9/4.T3 (III) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 5647 9000. Fax No.: - 022 5502 4123. Registered Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai 400 013