DATA FORMAT FOR REGESTERING COMPLAINT

*Name of Complainant

Communication Details

*Door No./ Bldg/Name/ Floor

Street / Area

*City/Town/Panchayath/Village

Taluk/Tehzil

District

*State

*Pin Code

E- Mail

Telephone No

*Mobile No

Fax No

*Insurance Type (Please mentioned Insurance Type

*Life

* Non Life

*Insurance Company Name

*Date of Birth of Policy Holder

*Policy No:

Cover Note:

Other Reference No:

Policy serving Brach Code/Address

*Details of the Complaint (Please type the full details of the complaint)

*Have you Approached Insurance Company Regarding This Grievance (If Yes Provide Ref No )
* Mandatory Fields

Mr./Ms. ANKIT AGRAWAL

114 SCHEME NO 71-D SECTOR-D BEHIND ASTHA HOSPITAL

INDORE

M.P.

452009

9926668897

HEALTH INSURANCE

NON LIFE

BAJAJ ALLIANZ GENRAL INSURANCE COMPANY

10/25/1984

OG-18-2302-8409-00000888
COMPANY IS DENING TO PROVIDE CLAIM FOR SOME DISEASE

YES THE NO IS 74796131