UNITED INDIA INSURANCE COMPANY LIMITED

Administered by Medi Assist India Private Limited Registered Office :# 49, 1ST Main Road, Sarakki Indutrial Layout, 3rd Stage, J.P. Nagar, Bangalore - 5600078 Claim form for Group Mediclaim Insurance

Address of Policy Issuing Office

Bangalore Divisional Office X No. 21, St. Patrick's Chruch Building, Museum Road, Bangalore 560 025 Tel No : 25588527 Fax : 25586853 E mail : ui72400@vsnl.net

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Name of the Employee Employee ID Date of joining Contact Numbers Name of the Patient Age in completed years/Date of Birth Relationship and Occupation

Mrs.

VASANTHA S
vasanthas@hp.com

20364273 E-mail Telephone Date of Birth Self

1-Oct-2007 Mobile 14-Jan-1982 Age in Years Occupation 9740333900 28.00

Pricing Analyst in HPIS

Nature of Illness/disease/accident Primigravida at 21 weeks + 4 days with IUI Conception , GDM on diet control with threatened Date of Injury/Illness/Disease (First Date of Illness or disease or accident) Date of Admission Date of Discharge 3624 In words CITI Bank Bangalore 30-Oct-2010 30-Oct-2010 1-Nov-2010

10 Period of Stay in Hospital 11 Amount Claimed in Rupees 12 Name of the Bank 13 Bank Branch Account No ( approved amt for the claim will be directly credited to your a/c) Name of the Accountholder as appearing in the Bank statement

Ninteen Thousand Four Hundred and Eighty Two only

14 City/Town where the Bank Branch is located Bangalore 15 16 5701358807 VASANTHA S CITI0000004

17 IFSC Code of the Bank Branch

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I have incurred on the treatment of disease/illness/accident referred to above, the expenses as per details given by me in the Schedule of Expenses overleaf. In support of the above claim, I enclose the following documents:(to be ticked) Bills, receipts and Discharge Summary/Certificate/Card from the Hospital. Cash Memos from the Hospital/Chemist(s), supported by the proper prescription. Receipt and pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner Surgeon demanding such pathological tests. Surgeon's certificate stating nature of operation performed and Surgeon's bill and receipt. Attending Doctor's/Consultant's/Specialist's/Anaesthetist's bill, receipt and certificate. Certificate from the attending Medical Practitioner/Surgeon that the patient is fully cured. I further authorise the Company to apply and obtain any Medical Reports or documents or information from the concerned Hospitals / Medical Practitioners who attended on the Insured person. The duly filled and signed claim form along with all the original bills have to be submitted to the HR Department of the respective location.

Date : Place : Bangalore

Name and Signature of the employee

Sl. No

Schedule of Expenses Name of the Hospital, Doctor, Bill No Medical Shop 1 BACC Health Care PVT LTD - DR Kamini Rao 109014 2 Parimala Pharma 12943

Bill Date 11/1/2010 10/30/2010

Amount Claimed 3000 624

Grand Total

3624

File : 61497040.xls

Run Date : 06/24/2011