Date :____/____/________

SELF DECLARATION

To,

The New India Assurance Co. Ltd., DO: 121200

TPA - Medi Assist Insurance TPA Pvt. Ltd.

Policy Holder – (Unit-HR name)

This is to declare that I Mr/Mrs/Ms __________________________________________________

Age ______ Years, Gender ______ holding a policy with The New India Assurance Co. Ltd., with

MA-ID card no. ________________ Claim ref. No.(in case pre/post hospitalization claim) ____________ .

I have submitted / want to submit the claim for myself / my dependent ____________________, but
due to current situation of lockdown (due to COVID 19 restriction) I am unable to send the required
documents. Hence I am sharing / uploading the soft copy of those documents in support of the claim,
request you to consider the same & process the claim on submitted documents. Once the restrictions
are lifted & situation gets under control I will be in position to deliver the original documents to you.

I also declare that these documents will not be used for claiming under any other policy and shall submit
the same within 15 days or immediately after COVID 19 restriction are eased or lifted whichever is
earlier. If any information & documents found to be misused by me in any manner the recovery of the
claim amount, if any, will be borne by me.

Thanking you,

(Name of Employee / Policy Holder)