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  • Reimbursement Claim Form

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    Aditya Krishna
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    HOSPITALISATION and DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM POLICY NO: 11270034130400000100 NAME OF COMPANY: MPHASIS LTD. DATE: Employee Name Employee ID Email: Date of Joining Contact details Phone: Cell: Name of Employee Age Gender Nature of Illness Name and Address of Hospital where treatment was availed. Date of Admission Date of Discharge Amount Claimed (in Rupe

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    HOSPITALISATION and DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM POLICY NO: 11270034130400000100 NAME OF COMPANY: MPHASIS LTD. DATE: Employee Name Employee ID Email: Date of Joining Contact details Phone: Cell: Name of Employee Age Gender Nature of Illness Name and Address of Hospital where treatment was availed. Date of Admission Date of Discharge Amount Claimed (in Rupe

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    © All Rights Reserved
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    11 views1 page

    Reimbursement Claim Form

    Uploaded by

    Aditya Krishna
    HOSPITALISATION and DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM POLICY NO: 11270034130400000100 NAME OF COMPANY: MPHASIS LTD. DATE: Employee Name Employee ID Email: Date of Joining Contact details Phone: Cell: Name of Employee Age Gender Nature of Illness Name and Address of Hospital where treatment was availed. Date of Admission Date of Discharge Amount Claimed (in Rupe

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    © All Rights Reserved
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    The New India Assurance Company Limited

    Registered & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai 400 001
    HOSPITALISATION & DOMICILIARY HOSPITALISATION BENEFIT POLICY
    CLAIM FORM
    POLICY NO: 11270034130400000100 NAME OF COMPANY: MPHASIS LTD. DATE:
    Employee Name
    Employee ID
    Email:
    Date of Joining
    Contact Details Phone: Cell:
    Name of Patient
    Mediassist ID Number (MAID)
    Relationship with Employee Age Gender
    Nature of Illness
    Name & Address of Hospital where
    treatment was availed.

    Date of Admission Date of Discharge
    Amount Claimed (In Rupees)
    I hereby declare that the above details are true to the best of my knowledge & belief and i have not supressed any information whatsoever.






    Signature of the Employee
    -----------------------------------------------------------------------------------------------------------------------------------
    Discharge Voucher

    I hereby acknowledge receipt of the amount Rs. __________________ (Rupees ______________
    __________________________________________________________________________ only)
    by bank Transfer to my Bank Account No. ______________________________________ in my
    Bank ___________________________ Branch _______________________ towards full & final
    settlement toward my Medical Claim CCN# ___________________under above-mentioned policy.


    Signature of the Employee

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