Professional Documents
Culture Documents
b) SI. No/certificate No :
SECTION A
c) Company / TPA ID No :
d) Name :
e) Address :
City :
State :
Pin Code :
Phone No :
Email ID :
Yes
No
SECTION B
c) If Company Name :
Policy No :
Yes
Diagnosis :
Date :
No
Yes
No
Male
Female
Service
Self
Months
Child
Spouse
Homemaker
Self Employed
d) Date of Brith
Father
Student
Mother
Other
Retired
SECTION C
c) Age : Year
(Please specify)
(Please specify)
Other
City :
State :
Pin Code :
Phone No :
Email ID :
DETAIL OF HOSPITALIZATION
c) Hospitalization due to :
e) Date of Admission :
Day Care
Injury
Single Occupancy
Illness
y
Maternity
m
Self Inflicted
Yes
f) Time : h
Twin Sharing
g) Date Of Discharge :
Yes
No
No
h) Time : h
i) If Medico legal :
Yes
SECTION D
No
j) System of Medicine :
DETAIL OF CLAIM
a) Details of The Treatment Expenses Claimed
i. Pre-hospitalization Expenses :
Rs.
Rs.
v. Ambulance charges :
Rs.
Rs.
Rs.
Total
viii. Post-hospitalization Period :
days
Yes
No
Rs.
days
Rs.
Rs.
Rs.
iv. Convalescence :
Rs.
Rs.
vi. Other :
Rs.
Total
Rs.
SECTION E
ECG
Other
SECTION E
Bill No
Issued by
Date
Towards
Amount (RS)
2.
Pre-hospitalization:
Nos
3.
Pre-hospitalization:
Nos
4.
Pharmacy Bills
5.
6.
7.
8.
9.
10.
SECTION F
1.
SECTION G
a) Pan :
e) IFSC Code :
Date :
Place :
ANTI-MONEY LAUNDERING REQUIREMENT (For claim more than or equal to Rs. 1 Lakh - One Document each from (1) and (2))
1. Proposers Identification (a) Passport (b) PAN Card (c) Voters ID Card (d) Driving License (e) AADHAR Card
2. Proposers Address (a) Current Telephone /Mobile Bill (b) Current Bank Passbook (c) Electricity Bill (d) Ration Card (e) Valid Rent
Lease Agreement
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, my right to claim reimbursement shall be forfeited. I also consent & authorize 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.