The New India Assurance Company Limited

4
Ro1d, Fort, Mumb1I · 00 001 .
Reglstorod & Head Office : Now lndlo Assu,once Bulldlng , 87, M.G.

CLAIM FOAM FOR MEOICLAIM INSURANCE POLICY

the claim on the part ol the lnsurors
Issuance ol this lorm does not amount 10 admissio n ol any llablllly under
Company to proce5S you r claim promptly
Please g,ve tho loll0wmg Information cnrroctly and completely '" enable
All dates to bo entered as Date I Mon tn , Year

1. Name of the Insured LIFE INSURANCE CORPORATION OF INDIA - (AGENTS POLICY)

2. Name of ,11e Agent

3. Agen t Code

4. Address

Teh~i l I Taluka
Cit yffown/Village
Di stric t
State - - - - --· - - - · · - - -- - -- - - - - - -
----
Pin code
STD Code :-_ _ _ __
Phone No
Mobile No
Em~11l Id

5. Nature of Disease/Illness cont racted or inju,y sustdir,G d : - -- - - - - - - - - - - -- -

6. Date on which injury was sustained/Disea!> 2
Or illness first detected
7. (a )N-'lrne and Address of the attending
Medical Practitioner
Pin Code
--------------
------------
State/ U. Territory
(b) Oua l1 f1cc.1tion & Telephone ~Jt.
(c) Reg1stra11on No.
(d) Na1'1e J Address of the Hosv:11/Nursi ng
Ho,11 ° Clinic - - - - - - -- - -- -
r·1r, Code - - - - - - - - - - - - - - -
~· -' ti:: U. Territory

(b) c,~1•: : ,/ " dm1ssion

(c) C . . :.;,:;cha rge
 ls
ose tho lollo wing orIglnoI dor.urnon
In support of the above claim, I encl

lo / card lrom lho Hospital

1 B1 11, Rece ipt and Discharg o cerll lica
/ Chem,s1s (s) , §_UQpor l~J QQ or
rucw.J!QM..
2 Cash Memos lrom the Hospliols (s) nd1
tho noto from tho atte ng Medi
cal
rts lrom Path olog ist supp orted by
Receipt and Pathological test repo
3
g such Pa lholog,ca l les ts
Praclihon or I Surgeon recomme ndin · blll and receipt.
of opera1,0 n pt:1rlr, rrried and Surg eons
4. Surg eo"'s ce rtifica te statin g n,1ture receipt, and ce rtificate regarding
Specialist's / Anesthelist's bill and
Atlen ding Doctor's/ Con sulta nt's/
5
diagnosis
ing treatment at home.
Practi tioner givin g reas ons for allow
6. Cert1f1r,;ite from attending Medical
nt 1s fully cured.
Pracllt1on er / Surg eon that the patie
7. Cer1 1t1cate lrom attending Medical

memos are enclosed .

which origi nal bills rece 10•~ I r.ash
I
Summary of exoenses incurred for Rs._ _ _ _ _ _ _ _ __
To!al of ~ospItal B111
Fees Rs . _ __ __ __ _ _ __ _
Co's ultanf's /Surgeon 's /Ane sthe tist's Rs ._ __ _ _ _ _ _ _
_
D1agnc,s 1 cs Tests Rs._ _ _ _ _ __ __
_
Med, : 1£> !> purc hased from cl,t:·inists Rs . _ _ _ _ _ __ _ _
_
Othr.r expe nses not included c1~ov e Rs._ _ _ _ _ _ _ _ _
Gra:->d : ci al
I agree that if I have mad01e or shall
oing particulars in every respect and
I he1•.:~•>' ,,arrant the truth of the foreg my right to claim reimbursement the said
t, suppression or concealment
ma k~ ~~·,_false or untrue state men
expenses shall be absolutely_l9rfeited.
admissible under any other Medical
the above treatment. no benefits are
I further declare that. in respect of
Scneme or Insurance.
TRATOR TO SEEK MEDICAL
ISE ·, HE THIHD PARTY ADMINIS
I AL~ CJ CONSENT AND AUT rlOR ICAi.. rn ACTITIONER WHO HAS
AT ANY TIME ATTENDED
r!ON FROM AN Y ;-;OSPITAL / ME:D
IN f Gi11', ,1-,
ON·,'.::.
itions and limitations of the policy
•' TPA to make payrn'c nt of the claim adm1 s'. 1o!e as per terms, cond
I a,_ ,t'l 1m .
and final settlement of hospital bills
to the rospital on my behalf for full
bursement of hospital bills incurred
I I a I~,., " .'''lonze TPA to recei"r n8~mP.nt fro111 Inst 'fil Vi'l company as reim
on 11v !1r.a lment.

.. d,1{ c 1 . .. ...... .. .. ...... ... 200

Oated at .. .. .. ... ... ..... ...... ...... .. this .. ..... .. .. .

Signature of the Claimant

tt,::: claims attached as per ann

exure - 1
Note : Chec1c1 .sl /or submitting