Tat AG General nsrance Company Lina SP, Sth Fo, ling No ny Pak Gan. AK Vie Marg, indo Malad ae) Mum 20097 IMPORTANT 1. Issuance ofthis form is not an admission of Laity ora waver ef he terms, condans and exceptions ofthe insurance contrat. 2. No daim willbe adeitee without a Mesical Report as per format to be obtained at caimant’ expense, [Name tn bloc eters) hued bycamane ies oy suse Prone) fu eal he i Tine ane oleh Pace ae tcaton ated cae becrpton Seay ed reas retatdalemene on mavens * 1) Nare aes oy sae Prove 2 Name aes ey sae Phone Policy No. PN ® ccupation (inwords) PN Mobile Pav MobileERS Adress Phone Registration No Name of amily Doctor Adress Name oftosptal ‘6, CONTACT DETAILS ‘aderess where avaliable Phone (Please be available at ths place where our representative may cll on you) AC TENE {This should be the actual days when flly confined to bed on Medical Advice} 1, Paria Confineme (his shoul be the days whan partial confined to bed) PEE A. Total Temporary Disablement Amount) 8. Permanent Diablement ‘Amounts Medial Expenses Amounts) D. Death Amounts) pESnso [A Have you made any claims inthe PAST? ves [No 2. IFVES please gve details including accident and insurance details 10, Areyou insured under any ter poley? ves [No YES, lease gve fll details 1 Have the Poles Authorities been informed ofthis acisent? ves [No hereby declare that| have suffered injuries ax described above ang al the detals given are ABSOLUTELY TRUE AND CORRECT. | herby agree to forfet al my rights to compensation If any of the foregoing facs and / or deta are found to be false or incorec. I further Suthorse the hospital doctor clagnostie abortory, organisation, estabihrven: or any ether Body or person ek within the eouree of {his clam to glue any information or dacument sought for by the Insurance Company. bate Pace Sera ofthe suredATTENDING PHYSICIAN'S STATEMENT PLEASE ANSWER ALL QUESTIONS 1. Name of njured Person 2 Age 3. Address Prone 4. Natur ofthe Accident and Detais of Injures Sustaines 5. Does the Cause of Acident as stated by the Claimant tally with the Injuries noticed by you? 6. Are heinjres solely due to the aeident or waceabl to any previous inure! disease intrest 17. Was the injured person suterng fom ary dlseaseor Injury Which may have contributed othe accident or Ikely 0 aggravates ‘eonditon, 8. Was the Claimant hospiaies? If so for what periog? 9. What retmant was given and Operations performed? 0. Give all ates of treatment: ClinieMospitat From. te Home: From te 11, Was he under the infuenceof intoxicants or drugs atthe me of aceden? 12, Are you his usual medical vendant? \f you have treated rim for any previous ness or injury, please give deals 13, Have other Doctors been Atendance ar Consultation? tyes, lease ge detals 14, Has his acedent been reported tothe Police Authories? yes, Case No: alice Station 15. Isthis claimant Totally Disabled from each and every occupation? 16. (@) How long was or il the clsimantbe totaly disbles from current occupation? From vo (too long mas or wil the claimant be parallydsabied fom current occupation? From ve. (@estmated date of tur to Work 17, whatisthe Prognosis. Bocors Senature pate; een io Doctors Name Aderess and Pnone No, ProneTata AIG General Insurance Company Limited Registered office: Peninsula Business Patk, Tower A 15th Foor GK. Mare Lower Pare, Mumbai 400 013, For more information Email us at customersupporrataag.com or visit wamtataaig.com Contact us on our 24 hou Tol ree Helpine a 1800266 77800 1900 22 9966 only for seni eizen poly holders) Insurance isthe subjec mater ofthe solétation