SBI GENERAL INSURANCE LTD

______________ (Location)

I do hereby solemnly affirm and declare as under that:

 I __________________________________hereby undertake that am Policyholder of SBI

General Insurance company, bearing Insurance Policy vide
No.____________________________.
 I hereby declare that I shall not produce, use or claim the physical copy of the electronically
submitted claim documents submitted to TPA NAME (attached herewith) at any other
Insurer/ TPA for whatsoever reason except in case where Sum Insured available (incl. bonus)
in present Insurance policy is not sufficient to cover claim amount fully and I have other
Insurance policy /ies to cover balance claim amount from either same or different Insurer
wherein certified copy of same claim documents will be produced without any unethical
intent to claim the amount twice.
 I shall ensure that the hard copy of claimed hospitalization documents shall be submitted to
NAME OF TPA within 30 days from date of lockdown is over and dispatch facilities
( Courier/Post) resumes.
 I shall forthwith reimburse or indemnify Insurance Company for the claim amount in case of
fraudulent, duplicate, forged and manipulated claim submission or if this self declaration
found untrue and dishonest.
 SBIG/TPA will have right to investigate the claims (even after settlement) and in case if any
discrepancy noted from scan copies and original documents and other information provided
or non-disclosure /misrepresentation then SBIG/TPA will reserve the right to recover the
amount. In the event there is any fraudulent action found in submitting the scanned
documents, SBIG reserves right to take action against errant entities, as per law.

Your’s Sincerely,

Name & Signature of the Claimant

Place :- Date :-
Note :-

1 This declaration for submission of claim on scanned claim documents basis and is valid only for the
lockdown period declared by Government.

2. All claim documents shall be self attested and to be submitted along with the signed declaration
and self attested Identity Proof.