Group mediclaim - Associate, Family & Parents

Tracking No : D290120221045347914

Employee Details

Employee name Akershit Agarwal Employee number 666635

Employee's location Contact number 7720086945

Employee Bank A/c Information

Account holder name AKERSHIT AGARWAL Bank Name STANDARD CHARTERED BANK

A/c Number 27*******13 IFSC Code S*********1

Branch Address B2 T***************PARK

Details of the claimant (Patient Details)

Name Radha Maskara Relationship Spouse

Claim Details

Nature of illness Migraine

Clinic Name Clinic Pincode

Total amount 5230

Medical Expencess breakup

No Bill No. Bill Date Bill Amount Remarks

1 MLOPBL/22235296 21-Dec-2021 800 10

2 MLXTBL/22036776 21-Dec-2021 100 4

3 UP02/21/S-72840 21-Dec-2021 677 14

4 0010122 16-Jan-2022 323 14

5 21-22/84920 26/12/2021 26-Dec-2021 2530 2

6 MLOPBL/22245754 01-Jan-2022 800 10

Declaration
I hereby declare that the information furnished in this Claim Form is true & correct to the best of my knowledge & belief. If I have made any false or untrue statement,
suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA or insurance company to seek necessary
medical information from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the
Bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the Post - hospitalisation claim, if any.
I also declare that I have attached a self-attested copy of the prescription letters/ consultation letter / diagnostic reports along with the claim documents as supporting
documents. I will not use them for any other insurance claim or monitory purpose.

I hereby further declare that I have submitted the claim for myself / my dependent through online portal/app. I have uploaded the soft copy of the documents in support of my
claim but due to the current situation of lockdown (due to COVID 19 restriction) I am unable to send the required documents immediately. Request you to consider the same
& process the claim on submitted documents. Once the restrictions are lifted & the situation gets under control, I will be in a position to deliver the original documents to you. I
also declare that these documents (Prescriptions/ reports/ Bills etc.) will not be used for claiming under any other policy.

Date Employee Signature

Date of Submission
 ONLY FOR OFFICE USE

HID Updation :- Required? Completed? Dummy Claim :- Action Required? Completed?

Document Checklist(Mandatory) To be filled by Help Desk / Front Desk

Claim Form Cheque Verified with CF and Name

Bills No of Pages [ ] Main Bill / Breakup available? Total No of Docs

Dis. Summary No of Pages Reports

Remarks :-

Non Scannable Documents (To be filled by Inward / Receiving personnel)

Nos Description

CT / MRI Scan

X-Ray

CD

Lens / Implant Sticker

Test Strips

Other

------------------------------------------- HELP DESK / CRM ------------------------------------------- RECEIVER / INWARD ------------------------------------------- SCANNING SEAL