SHRIRAM CLAIM FORM “B” YOUR PARTNER FOR PROSPERITY srs Sankar one vata 73 “6” Divisional Office: Branch Office: TRI ar MEDICAL ATTENDANT'S CERTIFICATE fefessr afterates sib hereE (To be completed by the Medical Attendant of the Deceased in his last liness) GA OF SIESTA ATT PSSST 5R7 FATS A) In connection with claim under Policy No ox Sax Bea fh On the if of agen oft ae (inser ful name of the deceased) (16H 4 am RH) 1. What was the ful name, addrass and occupation ot Name : eR ar am, (Serer @ crm Fe AR a: Aesiross: ‘Sem Occupation: ct 2 (A) Wat a nay ax you cud udp was He a of (e) Apperen Age OIC Yer EEE seoens ate err ‘aah Tet So Fe SR FAS TTS SRS TR, EN TAT Fs Ar? ®) (0) Was he eat oyu ano, ow? one a ae Re, IT (©) Peoue deat any mets pyle pecilares © Seorrare ere fee Ae ‘efiRy gere T ay aR? What wos te ean dof er At cece Kam (Clem Seige oe Se Be Jaw Op on 9 OOO 4. Whore did he/she dle(Give exact adess) cores FRET TH CTE Bem AY? 5. (A) What was the exact cause of death? (Besides defining the disease or other cause of death in such terms as you consider appropriate, [Kindly add the distinctive technical name. ]) Giga Be wae fe RR? (aes ar eT fete > Garage Set wae ROSS AE TOT [SEE RAR safes am IF TR]) (8) Was it ascertained by examination after death or inferred from symptoms and appearance during ite? oft fe age mao HOR a Serer Sent Ne oe Ge aE Sa TART? (a) Primary cause. ante 374 Secondary cause feSix eae ow)(C) How tong had he/she been sutfering from this disease before | (¢) his/her death? re GR ae wae FA oF cee ga? (©) What were the symptoms ofthe ness? ) eprarr empr f fe? (©) When wore they fst observed by the deceased? Cc) BoE OS sor aT HRA? (f) (F) What was the date on which you were the ilness? 2 ROR TAR Ore Co TR STE sane ORT ARO? (G) bi you attend him/her during the whole ofits course? If not, | (B) state during wnat period? ‘aft fe at gar saat oe BRST wa? aT SORT, CoM TN OTe BON TA? 3 consulted during 6, (A) Were his/her habits sober & temperate? Co ore es ora AD er? (a) (8) Have you any reason to suppose or to suspect that disease was in his case caused or aggravated by intemperate habits? | (by sora ore AF om FoR WE AT AE ED ca re eo] oT TAH ACA aT cS Fen? 7. What other disease or tness 2a) GO AT HR (0 preceded or ons fer aT (i) Co-existed wit that which immediatly caused his/her death? |" OF a FE TRE SP SE? Give history of such eisease or tnesssttng:- oe cay) re ANT HR Be = (a) Date when first observed? (a) 5 Re RT SoH? “ (©) By whor was it treated? ) Ce Room sara? (©) By whom was the history reported to you? o SWS OF aR TEE START? 8. (A) Was the deceased treated during his/her last itness by any | (a) ‘other Medical practitioners or in any Hospital before you were consulted? Iso, please state their names & addresses, are FAC OT LO CN SONS AHN oT way OS Seer um Sa em ponet Afb aay er Pe? SR UE ATE, SRO AGE FN ST A ok eT SOM SAT (8) Did any other Medical Practitioners attend to him/her in (0) consultation with you? If 80, please state their names & addresses say tem feoore aro ony fae Pasa? a oR TE, SR RTF OTE AR oe MT SEN A 9. (A) Were you the deceased's usual Medical Attendant? ah FF geR wmER PUT ARES Ree? () (B) If so, for how long? (b) af ot gor veh ae? (C)IF not, please state name address of his/her usual @ Medical Attendant? aa, Hoe eae eT ATER a 6 enn Sov se710. When and for what ailments did you treat the deceased during the three years preceding his/her last illness? OEE CAL aT Oo TEA AIT SMa Se Ce eT Bet ora Is RROAT wea? 11. Was any Inquest or formal Inquiry held regarding the death or was a post-Mortem Examination of the body made? If so, by whom, and what was the result or findings? age Fa core GM = angie oes aT Rake To conta sy er xe fH? APR OR AA, AH NT, It OT Fe Ror a fe Baer? 12. Have you any other information or remarks to make in connection with his claim concerning deceased's ailments, habits, mode of ving et? ZR SENT, were, Ser tam Ron ar os aa HCO ONE 1 WE te FT 1 a 3S the deceased Medical Attendant of anfePbomt “Psieeacere Hom DO HERE BY SOLEMNLY DECLARE that the foregoing Statomonts are true and comect to the best of my knowledge and belie, and thatthe deceased did nat die by his own act corer afc ee Py oom RON en oe FOOT mA o Her, a aCe Go one aS se mT TL Dated at this = ore ey of, ad Code No_____"_(State here the Code Number if you are an authorized Medical Examiner of the Corporation) cre a CamRE SR sueerae ape Run ee me we aT Cee ANAS Baw SH) Witness rt Name oe Signature Postal Address ue Signature and Seal of Medical Attendant fafironr afore rss ot Occupation om Qualifications caret Postal Address we Bem