Claim Form:

Policy number as mentioned on E-Card: OG-23-1919-8403-00000099

ID Card number as mentioned on E-Card: DTT-23-607043E
Insured Name: KANDUKURI SUPRIYA
Name of the Patient: KANDUKURI ANURADHA
Date of Admission: 09th -OCT-2022
Date of Discharge: 13th -OCT-2022
Claim towards Treatment of:
Total Claimed amount:

Sr. No: Date Bill/Receipt No: Issued By Towards (Pre/Post Amount

Hospitalisation/ Pharmacy Bills)
1. 08/10/2022 140780 Pre Hospitalisation 500/-
2. 08/10/2022 BIL35934 Pre Hospitalisation 2400/-
3. 08/10/2022 BIL35940 Pre Hospitalisation 880/-
4. 13/10/2022 OPO68168 Pharmacy 1215/-
5. 19/10/2022 BIL36222 Post Hospitalisation 800/-

Total 5795/-

I have incurred on the treatment of the illness or bodily injury referred to above the expenses as
per the details given by me in the ‘Schedule of the Expenses’ overleaf. I hereby warrant the truth
of the foregoing particulars in every respect and I further confirm and warrant that there is no
other information relevant to my right to claim or the amount of my claim with which would
have a bearing upon your consideration of my claim and with which you ought to be acquainted.
I hereby give my consent and authority for you to seek medical information (Indoor case papers,
reports, documents, including photocopies thereof / pertaining my, admission / treatment) from
any Hospital or Doctor from which or whom I have at any time sought or shall seek medical
attention concerning any disease/ sickness, ailment or injury,  which affects my physical or
mental health.

I also hereby confirm that the amount payable to me under the coverage terms and conditions
would, when received constitute full and final discharge towards my claim.

Name of the Employee: KANDUKURI SUPRIYA

Deloitte E-mail ID: kansupriya@deloitte.com
Date: 09/11/2022