PL 200Pads 100 6 98 (co) (a) (co) {e) (a) (c) (b) (2) (a) (b) (0) Dated __ FORM No. THE NEW INDIA ASSURANCE COMPANY LIMITED Rego. & Head Office: New Ins Assurance Bung, 67, Mahsima Ganch Rose, Fa, Bombay 400029, ‘STATEMENT OF CLAIM FOR HOSPITALISATION TREATMENT HEALTH INSURANCE SCHEME Issued to For OFFICE USE ONLY (employers name) Under Policy No: SC (ME) Claim No. WHC! ff Employee's Name. (b) Regn. No. A'BICID/E/S, No. (Grade) Residential Address _ PARTICULARS FOR WHOM CLAIM MADE Self 0] Wife 2 Son CI Daughter {b) Name: Date of Birth (d) Covered from Gay monthy (yea) ee) monty Geary (ln case of child) Whether Married: YES INO, (f) Whether employed : Yes ONO] (in case of dependant) (g)_Ifyes, by whom ? If an ACCIDENT involved answer the following When did the accident happen ? Date at (hour) am. /pm. (Gay) (monty; (year) ‘Was the injured person at work when the accident happened 7 YES C) NO 1) Give brief description of the accident : Type of iliness/disease suffered “The iliness/disease giving rise to this claim was first contracted on ay (month) (year) Details of treatment received and expenses’ incurred are given overleaf For other additional medical expenses not specially covered in this form, attach bills showing, Name of Patient. (b) Description of treatment, service or care, (c) Dates and (d) Charges. Each such bill should be signed by the attending physician or his prescription attached to show that such medical expenses were authorised as necessary by him. Did you or are you likely to receive any hospital, surgical or medical benefits or services provided under any other Plan or scheme or from any other source on account of the accident or illness for which claim is made ? YES C1 NO Dif YES" give details Name and address of Insurance Company or Organisation providing such benefits or services ‘Amount received or due Rs. Last claim made on *NEW INDI Date____ Claim No. respect of ebove named, Rs Total amount of this Ciaim z I hereby declare that the foregoing statements are true in every respect and are made without any reservation _ Signed (Employee) imPORTANT : PLEASE DO'NOT LEAVE ANY ITEM BLANK. 1 2. Sains formate. pleeee manton LMS (ast manstom pars Please tick ( ) the Square LJ applicable. Please read footnote overieat.(2) DETAILS OF TREATMENT AND EXPENSES Name of the Patient Age Room & Board ‘A. HOSPITAL CHARGES am ay ats Total Rs pm ‘Admitted to Hospital on at | Discharged on _____#t on a ; ome and Address ofthe Hospital otner Charges Anaesthesia Rs rrr Rs _ Bo Transfusion = Rs. Cl rrnting 1 stvery Room fs = . Surges Aplances Rs x Rov. 6. Bu Ps. Pathological Tests Rs ee > Dressing Rs. Medicines, Injen & Curate Meiers __Rs — Medicines purchased trom Chemists Rs Total Re. SPECIAL NURSE andlor WARD BOY GHARGES Name of NurseWard-Boy i Quaiicon Regn, No. Datas of Attendance rom, amon 18__to om on 1 Rs c F Bs pa e per day From am on 18__to ean 19__@ Rs. per night Total Rs. ©. SURGEON'S FEES Nature of surgical or obstetrical procedure (Deserve fly) ‘ere performed Date peromes Charges for above provedure Re. - (Rupees Anaesthetts Foes Rs. (Rupees. Signature Dparaing Suge) Dated 19 Across: __ 1D. CONSULTANT'S FEES: . Diagnosis CConsutation on @ Rs Total Rs Consultation on @ Re Total Rs Total Re. +} nad recommended the services of special Nurse/War- | cetty that | hed advised tne above patient to get admitted inthe Hospitel ang boy as in section 'B'( "tebe struck af not applicable) Signature a atoning Prysar) 19 Address Dates IMPORTANT + Entice In Sections A,B, © & D should be supported by Bills and Stamped Receipts trom the respective parties i Houpital Authorities, Special NurseNWard-Boy, Surgeon, Anaesthetist and Attending Physician. The Identification of the patient Le. his name and age must be referred to in the supporting papers. Ploae Attach Hospital Discharge Card/Patient's History Card In Original Itwill be returned After Processing the Claim.