Professional Documents
Culture Documents
d) Name :
S U R N A M E
F I
R S T
N A M E
M I D D L E
SECTION A
c) Company/TPA ID No:
N A M E
e) Address :
City :
State :
Pin Code :
Phone No :
Email ID :
Yes
No
D D
M M
Y Y
Date: M M
Y Y
Policy No.
d) Have you been hospitalized in the last four years since inception of the contract ?
Diagnosis :
Yes
No
Yes
No
SECTION B
S U R N A M E
Male
Female
Service
Spouse
Self Employed
R S T
Child
Homemaker
N A M E
Months
Y Y
M I D D L E
d) Date of Birth : D D
M M
Father
Mother
Other
(Please Specify)
Student
Retired
Other
(Please Specify)
M M
N A M E
Y Y
SECTION C
F I
c) Age : Years
City :
State :
Pin Code :
Phone No :
Email ID :
DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admitted :
b) Room Category occupied :
Day care
Injury
e) Date of Addmission :
D D
M M
f) Time :
Y Y
No
Twin sharing
Maternity
Yes
Single occupancy
Illness
M M
g) Date of Discharge :
D D
M M
No
Y Y
M M
Y Y
h) Time :
D D
H H
M M
Yes
No
i) If Medico legal:
j) System of Medicine
SECTION D
c) Hospitatization due to :
DETAILS OF CLAIM
a) Details of the treatment expenses claimed :
Rs.
v. Ambulance Charges :
Rs.
Rs.
Total
vii. Pre-Hospitalization period :
Days
Rs.
Yes
No
SECTION E
Pharmacy Bill
Operation Theatre Notes
ECG
Rs.
Rs.
Rs.
iv. Convalescence :
Rs.
vi. Others :
Rs.
Doctors Prescriptions
Rs.
Others
v. Pre/Post Hospitlaization
Lump sum benefit
Rs.
Total
Bill No.
Date
Issued by
Towards
Amount (Rs)
D D
M M
Y Y
D D
M M
Y Y
Pre-hospitalization Bill:
D D
M M
Y Y
D D
M M
Y Y
Pharmacy Bills
D D
M M
Y Y
D D
M M
Y Y
D D
M M
Y Y
D D
M M
Y Y
D D
M M
Y Y
10
D D
M M
Y Y
Nos.
SECTION F
a) PAN
b) Account Number :
e) IFSC Code:
(IMPORTANT:PLEASE TURN OVER)
Date :
D D
M M
Y Y
Place
SECTION H
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or
concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorise
TPA/Insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is
made. I hereby declare that i have included all the bills / receipts for the purpose of this claim & that I will not be making any Supplementary claim except the pre/post-hospitalization
claim, if any
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
d) Name
e) Address
Tick Yes or No
c) Company Name
Policy No
Sum Insured
In rupees
Tick Yes or No
Date
Diagnosis
Open Text
Tick Yes or No
b) Gender
c) Age
d) Date of Birth
f) Occupation
g) Address
h) Phone No
i) E-mail ID
c) Hospitalization due to
e) Date of admission
f) Time
g) Date of discharge
h) Time
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
Open Text
j) System of Medicine
Tick Yes or No
b) Account Number
e) IFSC Code