GENERAL teliancegeneral.co.in ReLIANCe INSURANCE 1800 3009 A RELIANCE CAPITAL COMPANY Health Claim form (The vance ofthis emis not b taken a an admission fbity- Please ve he allowing norman caret ane completely) vee Ena Pre Authorization obtained Yes /No 1. Type of claim [Hospitalization X] Pre & Post Hospitalization Hi Heath check up 1 opp 2. *PolyNo-L_4 1 4 4 4 4 1 pp pa a i ti i} Policy type: C1] individual [] Group GroupiCompany Name ¢orcrows tat rotenay Isthis a renewal policy [] Yes L] No Yes, previous year's poicyno Luo 1 yu 1 yy 1 ya | 3. _Detals ofthe Insured Person in respect of whom the claim is made Name L H Present completed age (in years) CJ] Gender: [] M [] F Relationship with the Policy Holder| *Card/ UHIO No, L J Suminsured © L J “Current Residential Address, | ay L J spIncodel_1 111 11 J state L | ‘Change of the contact Details [] Yes, | wish to change my contact details [_] There is no change in my contact details Please update mentioned mobile number as primary contact details against my policy. | provided below for Claim Status Policy Renewal Mobile Number 4, Profession/Oceupation [] Business ]Profession [J Salary [] Aaricutwral income —] Savings] Others © hereby conf to be contacted on the number 5. Monthly Income TD Upto # 20,000 O1 €20,001 050,000 1 ¢50,001 to¢ 1,00,000 11 1,00,001 and above 6 Aadhaar (UIDAN) NoMIDNo, La a a PANN Lo 8. Name of the Policy Holder (Self ‘Main Member) § (_______ smal [_ Employee ID / Client iD L411 141 11} 8. Does the claimant have health insurance policy with any other insurance company? Yes No des, phase rove me estas) Name of the Insurance Company | Policy No. L___J sum insurese_ _______] Policy Start Dato Policy End Date Name ofthe Insured | *Member 1D No. 10. Hospitalization Dota - Date of Aamission Date of Discharge Diagnosis / Nature of disease /liness contracted J injury suffered = [___ l H 11. Date of injury sustained or disease /ilness frst detected ‘An 180 900%:2008 Cortes Company Rare Heath: Relanes General insurance, No.1-89//Bi40 to 42hs/301, 31 for, Kishe Block, Krshe Sapphve, Madhapur Hyderabad 500081. IRDAI Registration No, 103, Reliance General Insurance Company Limited, Registered Office: H Block, 1" Flor, Dhirbhai Ambani Knowdgo Cy, Navi ‘Mumoai 400710, Corporate Offic: Reliance Cenze, South Wing, ” Flac, OM. Wester Express Highway, Santacrz (East), Mumbal- 400 05S. Corprate deny [Numbor USG603MH2000P.C128300. Trade Logo dsplayed above bolongs to Anil Dhrubhai Ambari Ventures PrivatoLimled and used by Reliance General Insurance Company Limited under License, RGIMCOMICOICOMMON.HEALTHCLAIMFORMer 1503071812. Details ofthe Hospital / Nursing Home in wnich treatment was taken Name ofthe Hospital / Nursing Home ‘Address of the Hospital Nursing Home city L J PIN Code L J state L J Mobile Number Registration Number 18, _ Name of Treating Physician / Surgeon QualfcationL_________] Registration Numiser_§ L____]} Telephone / Mobile Number L J emaitio Telephon 14. _Dstals of the amount claimed Bill Heads “Amount m2) Bil Date Bill attached (YesiNo.) ”_| Room Rent & Nursing Charges B_| Doctors Consuliatoniviel Charges © | tavestigation Charges(inclades Radiology and Pathology Reports) D_[_ Surgeon and Asst. Surgeon Charges E | Anesthetist Charges F_[_ Operation Theater Charges 6 | Medicine Charges{inchides Ward anc OT Medicnes and Consumables) H_| Taxes/surcnargesiService Charge 1 | Miscetaneousiother Charges (like Admission, Registration, st.) | Pre Hosptaiztion Bis (Any) k_|_ Post Hosptalization Bis (FAny) otal Claimed Amount (Sum of Ato K) In suppor of the above clam. | enclose following documents in orginal Please nica by king the Yes No} Cai form Duly Filles Yes/No | Investigation Reports/Reports Name Yes/No ‘Authorization Form Yes/No _ | Mecicine/Pharmacy Bils with Doctors Presciption Yes/No Discharge Summary Yes/No | implant Name and Invoies (any) Yes/No Hospital Bis Yes/No _ | indoor Case Papers (duplicate copy) Yes/No Hospital Payment Recoipt Yes/No | others Yes/No Photo Wdently Proot Yes/No Total No.of Pages enclosed 'AS por he poly lems and conditions, the Company reserves is ight to have the Insured examined by a doctor appoinied by i for varfcation of clagnosis. Please note: Incase the Health Gain Policy under which the claims is being lodged has been taken on instalment basis then in the event of claim being ‘admissible, the company wll deduct the balance instalments due any rom the claim approved amount and pay the balance due tothe Polcyholder. Inthe teventofthe claim assessed amount being lower than the Balance instalment. due then the Palicyholdri lable to pay te balance premium instalments due Irnmediatelyby cheque or OD. falling which the said Claim would be treated as inadmissible and the Poley shall stand cancelled mediately and no lability shall admissible under e Policy for any Claims lanl in futur orn period elapsed. 15. Name ofthe Bank Account Haider] MeL] Mes. Ms 16, Bank Account No, Liiiririsriit 47. Account: CJ Saving C1 Current 18, Name of the Bank fa to. braneh asad 20. MICR Code (sgt ER cade number fe bank and branch appearing onthe chu sind he ark) Loar 21. IFSC Code (11 character code appearing on your cheque la") understand that ay refund due onthe premium payment /any payment / claims tobe directly credited to my aforesaid Bank Account.” “Rs per IRDA, is mandatory that al payments made tothe insured are only through electronic mode. Note: Plesse attach orignal cancalle cheque and a copy of PAN card fr vetfeation ofthe particulars provided inthis regard‘Aadhaar Card No. (Note: Saf attested Aadhaar card copy to be submited) wish to collec claim reimbursement directly in my Bank account linked with my aforementioned Aachaar Card. | understand thatthe claim amount ‘shall be credited directly in my latest Bank account linked with my Aadhaar Card Uwe hereby declare thatthe deals given above are true and correct tothe best of my belie and knowledge. Inthe event above information or any part thereof is found incorrect, | agree that allright under the policy wil be forefeited.| agree to provide adeltonal information to the Company required. | Wil indemnify and hold harmless the Company due to any loss arising out of misstatement in this form and am willing if required, to make a statutory Declaration before a Justice of the Peace of the truth ofthe whole ofthe foregoing statement or ary other statament I may make in connection with this chim. |urther agroe and undertake not to receive from Reliance General Insurance Company Limited any rebate other than that mentioned i the published prospectus in accorcance with the provisions Section 41 ofthe Insurance Act, 1838 as amended by Insurance Laws (Amendment) Act, 2015. Date: (Signature of laimant) EEE 1A) Date of First Consultation (Prior to Hospitalization) 3) With what complaints was the patient admitted for {Detail history of past illness with duration D) Whether the present ailment is a compilations of Pre-Existng disease ? DateLor boyd yyy yy E) I yes ploa spocty the disease (OR) complication of any previous surgery done 2| F) Whether the disease / disorder is congenial in nature ? {G) tyes please spect the details Hy Nature of surgory/ treatment given for present alent 1) Number of in-patient beds inthe hospital (including ICU) (Doctors Sealand Signature) 41, The dotalls provided by the Customers in the Mandate form shallbe considered as nal and Rellance General Insurance Company Ld, Shall not be responsible for cross vertication of any of he details provided therein 2, The RTGSINEFT faclty shall be effective for the respective customer(s) within 15 days of he receipt of the Mandate form by Relance General Insurance Company Lid, andior within such period as may be reasonably required by Reliance General Insurance Company Ltd. to activate the RTGSINEFT facity 3. The Customer agrees that under the RTGSINEFT facily there may be a risk of non-payment inthe account of customer on the day ofthe credit of payments cus to change in the applicable regulations pertaining te RTGSINEFT facilty or due fo any other reasons without any faulVinactionalure ‘onpar of Reliance General Insurance Company dor any factor beyondthe controlof Reliance General Insurance Company Lt. 4, The customer agrees to indemnily, without delay or demur, Relance General Insurance Company Lid and its agents and keep Reliance G Insurance Company Lid ang its agent indemnified harmless a allies from and against any and allclsims, damages, losses, costs, and expenses (including attorney's fees) which Reliance General lneurance Company Ltd may suffer or incu, decly once, rising from orin connection wth amongst other things, ether ofthe aforesaid reasons stated in above clauses, 5, The Customer May discontinue or terminate the use of RTGSINEFT facity by giving a minimum of 15 days prior wien notice to Relance General Insurance Company Ltd. The date of notice wil be considered from the date of receipt of such notice by Reliance General Insurance Company Ltd “The notice of, such termination should be given to Reliance General Insurance Company Ltd. only at its corporate address and be addressed at Reliance General Insurance Company Limited, Rellance Centre, South Wing, 4” Floor, OF, Western Express Highway, Santacruz (East), Mumbai 400055, 8. _AConfimation of he receipt of termination notice given by the customer will be acknowledge through a confirmation Letter by Reliance General Ingurance Company Ltd, In no case can be the customer construe his termination notice as effective unless a contrmaton has been provided by Reliance General insurance tothe customer stating the date of Receipt ofsuch communication by the customer. 7. The Customer agroos that ransaction(s) through RTGSINEFT may attract inward RTGSINEFT charges, which floviedby the customers bank, shall be borne bythe customer. 8. Reliance General Insurance has the absolute discretion to amend or supplement any Terms and Condition stated herein atany time and willendeavor \o give prior notice of Ten days for such changes wherever feasible for the terms and conditions tobe applicable, By using the new services, or atthe completion of such periog, whicheveris eave, he Customer shall be deemedtahave accepted the changed terms and condions. 8. NEFT acityforgrouppolleyholdershallbe done at the consentof HR.410. _ Notices under hese terms and conditions may be given in wring by delivering them by hand or e-mailor on Reliance General Insurance Company Li website wiwreiancegeneral.co.inorby sending them by posttothe last address ofthe Customer. 11. These terms and conditions willbe governed by the laws of India and any legal action or proceedings arising out ofthese Terms and Consitons shall be Inlatedin the courts or tibunals at Mumbailn Ind, 12. We further undertake to refund any excess amount whether demanded by Reliance General Insurance Company Limited or not, which has been Cretited in excess to my account at anytime due to any reason within 7 days of such receipt ofsuch communication from Raliance General insurance of such excess creditor such information af excess credit coming othe knowledge of the customer through any other source. 13, IWeagree that mylour claim payment il be creited from the date Rellance General Insurance Company Ltd. ges confirmation from ts bankers, ths facity wil continue unlessitis revoked by any party and any issuance of elevant creaitineucton from Reliance General Insurance Company Li, tits bankers willbe val illsuch instrctions is complete irrespective of the fact that the notice period has expired provided such a creit request has been ‘made by Reliance Generallnsurance Company Ltd. before the expr ifthe notice period othe customer. 14. As per IRDAL any claimed amaunt above 1 lac, Copy of PAN Card/Form 80 ofthe insured for corporate reimbursement claim/Proposer for retail reimbursement claim s mandatory, andbelow tlacPhotoidentty proof for ag: Aadhar card, Driving license, Elation card, Passport ete)is mandatory 15. For NEFT sattlomants to insuredIPropaser we require CTS 2010 cheque, CTS 2010 compliant cancellad cheque should have Name of the Account holder, Accountrumber and IFSC code ofthe bank o be printedon cheques mandatory 16. Incase of Non CTS 2010 compliant cheque photocopy ofthe passbook/bank statement with all the required details (Name of the Account holder, ‘Accountrumber and IFSC code ofthe bank shouldbe printed on passbook/bank statement) shouldbe submited (Signature of te account holder) * Mandatory detalls tobe filed Please courier documents tothe below address: Rare Heath: Reliance General Insurance, No.1-88//8/40 to 42s/301, 3rd oor, Krshe Block, Krshe Seppe, Madhapur Hyderabad 500081. matt gelrcareheath@retanceada.com. Tis chim form stall bo applicable for Ralance HealhNiso Poi, Reliance HeathGain Polley and Group Meili. Ut af Rance HeathGan Poly: IROANL-HLTIRGUP-AWVISIB/3- 14, UN of Relanes HeakhWise Policy: ROANL-HLTIRGUP-HIV131518-14UIN of Group Media: UIN: ROANLHLTIRGP-HNVIST7I9-14