THE NEW INDIA ASSURANCE COMPANY LIMITED

JEEVAN SUDHA BUILDING

42C, J L NEHRU ROAD, 3RD FLOOR, Kolkata 700 071
CLAIM FORM FOR GROUP MEDICLAIM POLICY –DOMICILLIARY BENEFIT
(THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS ADMISSION OF LIABILITY)
Please provide the following information correctly and completely

Claim no :____________________________ ___Claim Date: ____________________________________

(Please note that the above information is to be filled in by Bata India Ltd)

1. Name of the Insured Bata India Limited

(i) Name of the Insured Employee Sagar

(ii) Salary Roll No./Emp Code 169653

(iii) Unit / Location 500

2 Details of the Person in respect of Whom Claim is made:

(i) Name Sagar

(ii) Relationship to the insured employee Self / Husband/Wife/Son/Daughter

(Strike out whichever not applicable)
(iii) Present Completed age 24

(iv) Contact number & email ID of the employee +91-9034696831,sagar.garg@bata.com

3. Nature of disease/ illness contracted/Ailment or injury suffered As Prescribed

4. Please indicate:
(i) Date of detection of disease/date of accident & self declaration
in case of accident
(ii) Date of completion of treatment Continuing
(iii) Name & Address of the attending Medical Practitioner Dr. V.K. Jain
Opp. Bharat Tek Kanya School, Jhajjar Road,
Rohtak
(iv) Qualification M.D.

(v) Telephone No. +91-7988097759

5. Total Amount claimed Rs. 2402

Items 1 to 5 have to be filled in strictly by the employee

Place :_____Gurgaon_____

Date:__22 January 2020__ ------------------------------------

Signature of the Employee