eu Flot No, PAPS.1, MIDC Phase I Chakan, Ta st ay Ne aTAMeTeTsoDH AN ‘Anusha Gangham Icici Lombard ‘cic Bank Tower, Plot No. 12 Financial District, Nanakram Date ~ 12/05/2021 yee ID -1001, Card No ~ IL 18462712600, Policy Number — 9 1 | was admitted in the {0 request for claim of my expense related toye1c! ELombard )Nisnaye Vaade._ 1C1CL Lombard Health Care Claim Form - Hospitalisation {suc ohio sat be hn a a as ab TTS Te A + Now submission of gn is and eis is th main reason fr daly li setae, eae provide the rials # mandatory documents + Toreceie update on your aim stats, provid our mobi we Ea 0 + You can track yur claim stats a ww cclambard.com->Cians & Welness Heath hin 6 Wellness Track ow eam TORE LED CARA LETTERS OMY {AX Typeot Claim: Main Hospitalisation Expenses Pro Post Hospitalsation Expenses 7 Colossus Wael) No ‘A2 Details of the Insured porson in respect of whom laimis made: (pation details) Name ofthe Patient: SURESH SIWADASAN Card No/UNID ofthe Patient: LL 4627/1260 0 J JJ III) Gender: Male~/ Female Date of Bitty 2I4)/))1 1/1 14)7I5) Completed ae: Yous 4.5) Monts 157 Occupation: Service seit Employed | Homemaker | Student | Retired _) Other (Please specify) Ae you pes covered by anya Meili Hent Insuance: 7 No_. es, Company name: Tecorine xT de Current residential address: FI LIAIT) JNO) j4)4)0/2 JWES)DOM PARK JONG JO JD) CCAN HONDA NEAR |PINOLEX) CAGLES IH ORBWADT PRT ci, PUNE saeMAHAGASHURA J Mabile no. 4! FE O5O)O) 1 LiL \tandine no. emt SUY ESWS UVa da SAN@yahiojo)-)\C/eiM ‘A3. For Groupl Corporate Policy For Individual RetailPocy ‘MemberID No/EmpoyeeI0 (ClentiD}: 16/0) 1)_) CleimintimationServiceRequestno: J J J JJ JJ JJ | HOVEX 1 F7264.94 1/0 1)/)00 O isthisarenewel policy: Yes No — Group’ Company name:"T © COMIN E X_) 1 )ny 0/2 |it¥es, kindy mention yourprevious policy no A LLe J jj) JJ JSS ree Ai NamectthePropeser: — TECONNEX ZNOUA jLuP |) jj) Relationshipwiththe Proposer*: EM PL O/YEVB J) j_|_J_J J) | CoumentPoicyNo: LONE // VST DEMT hj, cardNo/UHD: {)L)1%)6)46)2F)/)2. 6010 {-Peicy Hote Fret poy, Proposer ramereqed Fo Cope poley wrod pe rae) |AS. Nature of disease/illnesscontractogorinjury suffered for which Insured was hospitalized (Diagnosis): Bilobwal Covid 19 Preumow'er Nameothospitalwhereadmitted: Pj Ei44)\)/S) JMOL T) VSiPeCIALI TY WHOS PTTAL Roomeateporyoccipied:Daycare | Single occupancy’ insharig _| 3ormorebedsperoom __) Others DateotAdmssion |S /614./ 20)2]) Time: | 500) Dateot Discharge: 23)/6/4)/ 210)21) Time: |} $20) O Date ofinjury sustained or disease loess frst detected: 1) \)/Hy)/2Jo)241) ieygnvcace. Settee! — Rouivaticaccidnt | Sibsareabse/ Acooleonsunpion ‘Sires COUT —14 tMedicolegal: Yes) No- Reported to police: Yos _) Ne“) [MLC Report & Police FIR attached: Yes _ Ne (yes, attach report) systematMedcine. “Treakmert Cu Wespitade 1s Areyou covered under any Tapup/Adétional policy: Yes) NA7~ Hes, provide poeyo._ AVA ‘AT. Current covered by any other Meticlaim/ Health Insurance: ff Dateofcommencementofrstinsurancewithoutbresk AY Ae |) | Hove youboen hospitalized nthe las 4 years since inception of onmact: A) Date: pY A) 6) / J.J) ) Drnosis:_4/ ove youlodgod any claim aoinst this pricularadissondatettached bls with any ther Isurance compar yes, attach setement lee, Company name: _ NB PolicyNo,__ Ar Suminsured® WAP) ) |S) ‘8. Details of Claim claimed i. Presosptaizatonexpenses: < )_J_J_J_J_J_J ii Hospitalization expenses: 2 ii, Posthospitaizatin expenses: § % JJ) _J_J_J_J ‘Status atime fdischarge:Dischargetohome-” Discharge to another hospital Deceased _| Woaicaiecameut® 6 SE OLP’I-” (6@G00-F) Dt Detatset te precedare f ts Pe-eshoiantoncihed Wa_)No_) fs, PosuteritonNas | JJ JJ J_|_JJ JI Jemnant Sone €fttehes ‘rautherzatonby network hospital ntobtaind, gvereason: APO Beda Aver deve vik Stave & Date of injury sustained or disease/ilness frstdetected: A) 1 |/ O)A)/ 2 )a1) CTE: Wjry, give couse: Selfinfcted Aj f\-Rooditrafc accident | Substance abuse/Acohol consumption WMedicolegat Yes No Reportedtopolce:Yes_| No__| MLCReport&Polce FR attached: Yes_| No__ (tfyes,attachreport) FR no, 4p not reported to Police, give reason: ak Injury de to substance abuse/alcohol consumption, test conducted testablishths: Yes_| No__| (ifyes, attach report) 85. This section is mandatory oniy if your health policy is not provided by your employer ~ AJA ‘AY Dingess (CD 10 Code primary & aditional ignasis) {Primary diagnosis (with ICD 10 code) wh {i Additional diagnosis (with ICD 10 code) ii) Procedure diagnos (wih CD 10PCS code) | B) Nature of surgery/ treatment given for present ailment “C) Date affirst consultation (Prior to hospitalization) 1D) Presenting complaints of the patient during admission E) Past medical history of the patient along with duration of illness, N a (yes tach rt apt conan poe = F)_ Was the patient under influence of alcohol during admission 'G) Whether the present treatment ailment is a complication a pre-existing disease? 1) Tes. please spectty the disease (or) complication of any previous surgery done? ' is Chim Farm ste corec othe best or noe MD Ragibtes 2014/06/2635 i Registration NOCof Hospi (Rubber stamp ofthe hospital) ate: || Y)/ 01S)/2)0)2)\) Apert icy omen Conon Conan mene tga alae neds ee - usRecreee SU RES SP RORS AX nmetene & Ot Cf4 / LFIZESDE LOS D oem | LETTS ITN RE OS 8 Sep Cage Name = ee ee TE LONE SN 3 Sam Nantes > ema Same te mat SUNTS KS VAR SE eG Aner = eel 3 Secor ne ae ih he econ = Reger gy tele Seen ees: SORES ME _SA YR RR SA~ 4ecoesses its + Papeser alc Dota Gant net + eee Deetscee a Sd ~ Sacha Pore Plas Spices eae + eee ee SuPRERE CUS 2 USSR SBE += \S3L% 135472 ATE Tt BOSS BOK|w - Fue see | DEO TS BE K PEC i memecnenme + Ste See AkeETS9 S28 ee ee ee Se ee ae ee ee RS Se ee Se ee nn RN ee ee se ee nm rep ee na et ttm a a SE ee Se NFS A NE gma eT ee SR AR nT eeenigaemninneneaamrarenenantnneel Vistas a mem. ccorasc on - Nite ae Hea Sooentet so ~ tee ee LENS "Vorers Meneny cae Deving conse eso oettcaton a om ttcaton fhe empoyges ofthe es he Seren che pespectye CYROe Lee sssoed by Ungue Mntfiston Authonty of na contaning deta of Dare access on BNO RE {sb cant sssuntty NREGA dy Spray noice the Stat Government Letter bom a recognses Pic Authonty (as defined vader Section 2 (ot te Right formation Act 2008) o Audie Servant (as defined Section 2chefthe The Prevention of Compton Act 19887 vein the entity and “reser! Pe caster Passport Beco bt Raton card Letter hon ay recog pubic authority Current statement of Bank account with detais of permanent’ present essence assress as downloaded) Current jtssbook with detais of permanentipresent residence address (updated uto the pores ment) \tbd leas agreement alongwith rent receipt wich snot more than three months ot as aresitence root Teshove 8 pertaining to any kindof telephone connection tke, mobil, landing weve. te: provde itis nt ede than si months rom the date cf sewranceooerast Employers certicate as apreatatresidence (Certificates of empoyers who have i place systematic procedures for recruitment along with ‘aintenance cf mandatory records ots employees are generalyeiable) \Whtten confirmation from the hanks where the prospects a customer, regarding identification and proof ofresidence. Curent passbook with detais of present’ permanent residence address (updated tthe previous month) @scIctGLombard Nibhaye Vaade ———— Maiieg Address OC! Lor eather, IC Bak Tower, Pt No. 12, Finca Dstt, Nanatram Gu, Gachbowl, Hyderabad 00032 Registered Office Address: (OC Lombard Huse, 414 oer Saverar Mar. Near Sid Vinayak Tepe, Pratadev, Mumbai 400 025, Waites at wwiccomberd.com. + Bal we at + Tal Free Number: 18002668» Tl Fee Fax Number 1800-209 8880 IROA Registration No. 115,