Without Prejudice

SBI Life Insurance Company Ltd

Claim form Hospital Cash

.
-

TPA Ref No . ________________

Policy Number /
Mailing Address:

City/:

State/ :

Pincode/ :

Mail ID/ :

Telephone number/ .:

Other Policies with us/ : Yes/

No/

If yes then policy numbers/ 1.

(Tick what is applicable/ )

2.

3.

Have you already made any claims under the policy /

Yes/

No/

If yes then details /

INSURED MEMBERS DETAILS IF OTHER THAN THE POLICY HOLDER
-

Name of the Insured member/ :

Relationship with the Policy Holder/
Age of the Insured member/ :

Date of Birth/ :
CLAIM DETAILS/

The illness/disease diagnosed/ / :

Date of first consultation/ :

Date of Diagnosis/ :

Date and Time of Admission/ :

Date and Time of Discharge/ :
Number of days in the Hospital (including the days in the ICU) :
( ):
Number of days in normal ward/ :
Number of days in ICU/ :
Name of the Hospital/ :
Address of the Hospital/ :
Telephone number/ :
Email ID/ :
Name & Address of the consulting Doctor/ :
Telephone Number/ :
Email ID/ :
Was the treatment taken in the Hospital related to any disease which was existing prior to the Date of commencement of this
Policy?
Yes
No
?

If Yes provide details/ :
ACCIDENT DETAILS APPLICABLE ONLY FOR HOSPITALIZATION DUE TO ACCIDENT

Date and Time of Accident/

:

Brief narration of how the accident happened/

FIR No/ . :

Police Station name and address/ :

Telephone number/ :

Email ID/ :

Page 1 of 4
Version II (12.07.2012)

Without Prejudice
SBI Life Insurance Company Ltd
Claim form Hospital Cash

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CLAIM FOR FAMILY CARE BENEFIT

Are you claiming for `Family Care benefit? *
Yes
No
* ?

If yes, names of the Insured member/members who has/have been Hospitalized :
, / :
Name/
Relationship/
Family care benefit claimed/ Yes /No

POLICYHOLDERS DETAILS/

* Family Care benefit This benefit can be claimed when 2 or more family members covered under this policy are
hospitalized simultaneously for 5 days or more due to the same illness/ailment/disease or due to the same event of accident.
The claim forms in respect of both lives to be submitted simultaneously. The Family Care Benefit is payable only once in a
policy year to the Primary Life Assured and any unused benefit cannot be carried forward.
* - ,
/

ACCOUNT DETAILS OF POLICYHOLDER/

Name of the Bank/ :
Account Number/ :
Please complete the enclosed Direct Credit Mandate Form so that when the claim is admitted, a direct credit of claim amount can
be made to your bank account

MANDATORY DOCUMENTS TO BE ATTACHED WITH CLAIM FORM (PLEASE TICK)

( )

Copy of Policy Document/

Hospital cum Treating Doctors Certificate/
Discharge card and copy of all medical documents related to hospitalizations

Identity Proof of the Policy Holder/

Age Proof of the Insured Member/
PAN card copy of the Policy Holder (for online policies)/ ( )
Direct Credit Mandate of the Policyholder/

Page 2 of 4
Version II (12.07.2012)

Without Prejudice
SBI Life Insurance Company Ltd
Claim form Hospital Cash

.
-

DECLARATION/
I, the above mentioned claimant, do solemnly declare that the above answers and statements are true in all respects. I also agree
that SBI Life does not assume any legal liability or responsibility for the accuracy, completeness or usefulness of the information
mentioned above and will not be liable for any discrepancy in the accounting due to errors, omissions or misrepresentation due to
account details.
, ,

I hereby authorize any Doctor or other person, or any hospital, sanatorium, medical professional, hospital or other medical care
institution, insurance, support organization, pharmacy, governmental agency, Insurance company, employer, benefit plan
administrator, accountant, or financial advisor or any other institute to provide to SBI LIFE INSURANCE COMPANY LTD, or
any of its offices, or court of law any information regarding the health of the member/members insured under this policy. A
Photostat copy of this authorization shall be considered as effective and valid as the original.
, , , , , , ,
, , ,

, , /

Signature of the Policy Holder/ ____________________________

Name of the Policy Holder/ ________________________________
Address/______________________________________________________________
________________________________________________________________
Date/
Place/

_________________________________
_________________________________

Documents accepted as ID Proof / :

PAN Card/
Voters ID Card/
Driving License/
Passport/
ID card issued by any public authority /

Page 3 of 4
Version II (12.07.2012)

Without Prejudice
SBI Life Insurance Company Ltd
Claim form Hospital Cash

.
-

Direct Credit Mandate /

I/We _________________________________ (Name of Nominee/Assignee/Trustee) hereby authorize SBI Life

Insurance Co. Ltd. to directly credit the claim proceeds of Rs. __________________ to my Bank Account, as per
details given below:
/
_________________________(/ / )

___________________ ,

Anyoneofthefollowingisapplicable

Account No . _________________________________

Attachpreprinted(Name)cancelledcheque/

()

Bank Name ________________________________

Type of Account

Savings Bank

Overdraft

SelfAttestedCopyofBankPassbook/
Statement/ /

Cash Credit

Branch Name

OR/

Current

_______________________________

Name of the Accountholder ___________________________

IFSC Code No______________________________

IFSC
Mobile Number ____________________________

E Mail ID _________________________________@____________________
I agree that in case of any failure of Direct Credit, for any reason whatsoever, SBIL shall not be responsible. I
also agree that SBIL shall not be responsible/liable for any losses that may arise due to incorrect bank account
details provided herein above.

Policy Number ______________________________________

Signature of the Claimant _______________________

Date/ : _______________________________________
*Disclaimer - Please note that the direct transfer of the Claim proceeds to bank account to be made only if
otherwise possible and allowed by banks as per banking regulations, Direct Credit will be possible only if either
a cancelled pre-printed cheque leaf is attached or above stated account details are attested by branch manager of
the bank where the bank account is being maintained. SBI life will not be responsible and liable for any losses
occurring due to incorrect account details provided by Nominee/assignee/trustee.
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/ /

Page 4 of 4
Version II (12.07.2012)