Coringhy yours: se Aline General surance Co Ud OoAareT ana use Apert Rad Yer Pune 411005. Reg118 | CRE USSOIPNDOOOPLCOIS!9 ects eg ont: waar Emili-cuslomerarepbsjgalans ain “alre ne: 200200 858 taaaosostse (Tobe in lockleses) kd ‘CLAIM FORM FOR HEALTH INSURAN Pte ‘TO BEFILLEDIN BY THE INSURED ‘The issue ofthis form isnot tobe taken as an admission of lability, DETAILS OF PRIMARY INSURED 2) Policy No b) SI. No/Certfcate No ©) Company TPAID No apcustomer L| || | Et ttt) @) Company Name aus ployee No: g) Name: hy Address: 3 ary site Pin code Phone No Email DETAILS OF INSURANCE HISTORY 1) Currently covered by any other Mediclarn/Heathinsurance —|_]ves [_]Ne ©) date of commencementof istinsurance without break L_|_J_L J ottyescompanyname: LL LL ELL LLL ELLE Patey Sum Insured (Rs) 4) Haveyou been hasptalzed in thelast ouryearssince inception ofthe contract?|_Hes |_No Date Diagnosis [TT «) Previously covered by anyother Medclam/ Heath insurance: ves L_lNo f)ifyes, Company Name LLL Itt ! LI DETAILS OF INSURED PERSON HOSPITALIZED 4) Name ofthe Patient: ) Health card no ofthe Patient ©) Gender Male|_|female a) Age yeas|_| | months «) bate of tn LOL0 olny Lv Lv | f)Relaonshpof mary incured Sef|_|spouse|_Jchid|_| rather|_] Mother|_| other|_| (Pease Speci) )Occupaton:Served_| sellémployed_| Homeraket_| studen{ | Reted|_| other|_|(Pease specs) 1) Address (i ferent rom above). iy: LL J statel [| Jeincode:|| 1 1 1 II Phone No email: DETAILS OF HOSPITALIZATION 4) Name of Hospital where Admitted EEE 01035 ale oceupany|_[ win sarng|_|3 or more beds pe om | §) Room Category occupied Day Care{_| Sin 6) Hospitalisation due to: Injury|_| tlness|_| Maternity o d) Date of Injury/Date Disease first detected/Date of Delivery: [| D | [M| yy 3 ¢) Date of admission | 0] | [4 LY L ¥LYL¥ fp Timel H [F| [vv Jayoate of oisehargeL | | [La] LY LY LY Ly Jrytimet Lv 1) Name of treating docter. Diagnass ‘injury ive cause: Set|_| infcted__| Road rate Accdert|_| Substance Abuse /Alahol Consumption|_| i) Medico legal Yes|_} No| i) Reported to potice:Yes|_] No|_] ii) MiCeportand Police FR atached:¥es|_|No|_]})s)ste of MeineDETAILS OF CLAIM 2) Detals ofthe treatment expenses claimed LL Pre-Hosptalistion Expenses: ii. Post ospitaistion Expenses: v. Ambulance Charges vi Pre-Hospitalsation perio: ) Claim for Domiciliary Hospitalisation €) Details of Lump sum / cash benefit aimee iL Hospital Dally Cash ii. fticalillnss Benefit ¥. Pre/Post hospitalisation lump sum benefit Claim Documents Submitted ~ Check List ‘Claim Form Duly Signed original Hospital Breakup Bill LJ operation theater Notes u nal Doctors request for invest page of the bank passbook DETAILS OF BILLS ENCLOSED [SeNo | Bil No 1 D Dp To DLO LM, M wt w w w 0 w ts Ws ts i Health checkup cos fs Rs, vi. Others (code) Rs, a Toil ts cosl_| || vi. PostHospasaton period: days ves L] weL_] (tyes provide detain annenure) ts i. Surgical Cash ts. & iu Comalescence ts & voters bs Toa ts Copy of ci ination any original Hospital Main il Crgnal Hostal Bil Payment Receipt [_] Orginal Hospital Discharge SurnaryPharmacy Bil U ee LJ original Doctor's Prescriptions sscptre) L| others ation reports (including CT/MRI Cancelled blank cheque leaf with payee name printed, fname ofthe payee isnot printed on the cheque lea please attach copy ofthe fist FTawards Amount (RS Hospitalisation Main il Pre-Hospitalisation Bils_Nos Peost-Hospitaistion Bil Nos Pharmacy Bills DETAILS OF PRIMARY INSURED'S BANK ACCOUNT a) Name ofthe Account Holder (As per Bank Account) ) Account no (As appearing in the ue book) Bank Name dd) Branch Name & Address: ©) Account Type:Saving |_| Current cath credi|_| A) MICR No O)FSC Code: PAN Cheque / DD Payable Detail: i) ckyc No DECLARATION I nereby declare thatthe information furnished inthis claim forms true & cor ‘or untrue statement, suppression or co | 10 the best of my knowledge and belie have made ary false ect to questions asked in relation ta tis claim my right to claim -ealment of any material fact with reimbursement shall be forfeted. also consent & authorize Bajaj Allianz General Insurance Company Limited, to sk necessary mecical information f uments from any hospital / Medical Pracioner who ha attended on the person against whom this claim isrnade. Ihereby declare thatl have included all the bils/ receipts forthe purnose of his clan & that| will rate making ary supplementary claim except the pre/past-hospitaization claim, f ary. sNowoas 4NoWLOas MN © NoLLo3s Now03sa Bajaj lian Genera Insurance co. FS us C-SI Cura) DECLARATIONS — CLAIM FORM. 1. For retail polcies/individual customers: Consent/Declaration to be added in proposal and claim for CKYC no. \Ywe hereby give myfour consent tothe Company to verify and obtain myfour identity/address proof through Central KYC Registry or National Securities Depository Limited Portal forthe purpose of undertaking KYC verification. 2. Fordurdical person/non-indvidual customer: CConsent/Decaration tobe added in proposal and claim for CKYC no lve hereby give my/our consent to the Company to venfy and abtain my/our identiy/address proof through Central KYC Registry or Goods and Service Tax Portal or Ministry Of Corporate fais Portal or National Securities Depository Limited portal forthe purpose of undertaking KYC, 3. For Group Policies: CConsent/Declaration tobe added in claim form CKYC no. \ywe hereby give myfour consent tothe Company to verily and obtain my/our identity/address proof through Central KYC Registry for the purpose of undertaking KYC 4. Forluridical person/non-individual customer and Group Policies: CConsent/Declaration tobe added in claim form CKYC no. Vw hereby give my/our consent te the Cormpany to verify and obtain my/our identity/address proof through Central KYC Registry or UIDAlor through ary ather modes for the purpose of undertaking KYC pate: Loo) MJLvLvEvby | Place: Signature of the Insured‘GUIDANCE FOR FILLING CLAIM FO} RM - PART A (To be filled in by the insured) DATAELEMENT, DESCRIPTION’ FORMAT a) Policy No Enier the policy number ‘A allotted by the Insurance company 5) SL.Nof Cerificate No. Enter the social insurance number oF the certificate numberof social health insurance scheme As allotted by the organization ‘© Compary TPA TON, Enterthe TPA IONS Ticense number as alotied by RDA and printed in TPA documents ‘ajName Tnter the fullname of the policyholder Surname, Fist name, Middle name hy Address Enter the full postal address Include Street, City and Pin Code ‘SECTION B - DETAILS OF INSURANCE HISTORY ') Currently covered by any other Mediclaim / Health Insurance? Indicate whether curently covered by another Mediclaim / Health insurance? Tickves or No BY Date of Commencement of fst Insurance without break Enter the date of commencement of fat insurance Use dd-mm yy Tormat ‘Company Name tnter the fullname of the insurance company Name ofthe organization in full Policy No Enter the policy number As allotted by the insurance company Sum Insured Enter the total sum insured as per the poli In cupees Have you been Hospializedin the | Indicate whether hospitalized inthe last four years | Tick es or No last four years since inception ofthe contract? Date Enter the date of hospitalization Use dd-mm-yy format Diagnosis Enter the diagnosis details Open Text @) Previously Covered by any other —| — Indicate whether previously covered by another ‘Medica Health Insurance? Mediclaim / Heath insurance Tick Yes or No Tcompany Name Enter the fullname of the insurance Company Name ofthe organization a Tall ‘SECTION C- DETAILS OF INSURED PERSON HOSPITALIZED a) Name of the Patient Enter the full name of the patent Surname, Fist name, Middle name ©) Gender Indicate Gender ofthe patient Tick Male or Female ‘Age Enter age ofthe patient Number of years and months @) Date of Tnier Date of Birth of patient Use dd-mmyy format 1) Relationship to pamary Insured Indicate relationship of patient with pohyholder Tickthe right option. others, please specity ‘Occupation Thdicate occupation of patient Tick the rightopton. Fathers, please speci RyAddress Enter the full postal adress Include Steet, Cityand Pin Code )Phane Ns tite phone number ofpatient Ince STD code with elephon number i) E-mail Enter e-mail address of patient ‘Complete e-mail address ‘SECTION D - DETAILS OF HOSPITALIZATION ') Name of Hospital where admitted Enter the name of hospital Name of hospital in ull 3) Room category occupied Indicate the room category occupied Tickthe right option ©) Hospitalization due to indicate reason of hospitalization Tickthe right option «Date of injury/Date Disease Wrst detected) Date of Delivery Enter the relevant date Use dd-mm-ytormat @)Date of admission Titer date ofadmission Use dd-mmy fomat A) Time: Entertime of admission ‘Use hhumm format ) Date of discharge Enter date of discharge ‘Use dd-mm-yy format h) Time Enter time of discharge Use hhumm format i) injury give cause indicate cause of injury Tickthe right option lf Medico legal indicate whether injury is medicolegal Tick ¥es of No Reported to Police indicate whether police report was fied Tick es or No MUCReport & PoliceFiR attached | indicate whether MLC report and Police FiRattached|| Tick es orNo D system of Medicine Enter the system of medicine folawed in ‘Open Text ‘eating the patient ‘SECTION E - DETAILS OF CLAIM a) Details of Treatment Expenses Enter the amount caimedas teatment expenses in rupees (Do not enter paise values) 8) Claim for Domicliary Hospitalization Tnaicate whether claim is for domiciliary hospitalization Tick Yes or No © Detals oF Lump sum] cash benefit claimed Enter the amount aimed as lump sur cash Benet Tn Fupees (Do not enter palse values) Chaim Documents Subrited- Check Indicate which supporting documents are submitted Tick the right option ‘SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT 1b) Account Number. Enter the bank account number ‘As allotted by the bank ‘€) Bank Name and Branch Enter the bank name along with the branch ‘Name ofthe Bank in ful i} Cheque? DD payable detals Ener the name ofthe beneficiary the chequel Name ofthe individual DD should be made out 10 ‘organization in fll IFSC Code Enter the IFSC code of the bank branch FSC code ofthe bank branch in fll AYPAN Ena the permanent account numb" Asal by te income Taxdepartient SECTION H - DECLARATION BY THE INSURED Read declaration carefully and mention date (in dd:mmiyy format), place (open text) and sign.Coringhy yours: Sap allan Fase Aor fone Yr Pe —40100.Reg113 | CN-USSOPNGEOOLCEIS29 re dtas egono: waning GE ne) Emad: custometreasutanz coin Tal ree no, 1800-20888, 02020205858 ER) “TO BE FILLED IN BY THE HOSPITAL ‘The issue ofthis form is not ta be taken as admission of liability Please include the original preauthorization request frm in ieu of PART-A obe edn pc eters) DETAILS OF HOSPITAL 3) Nameot the hosp ) Hospital: ©) pe ofhosital: Network ] Non Nework C](tnn-nenvor flection) 9) Nameot venting doctor ©) Qualification: Registration No with tate Code 4) Phone No: 1) Rohini ode. 1) NABH CODE ) stateLeve Certfiate 1 Higher evel Ceri 1) National Quality Assurance Standards, 1m) National Health System Resource Cs DETAILS OF THE PATIENT ADMITTED 3) Namecithe patent ©) Presson ember conde Woe F]femle] dae ean_| J wants pate Wh time [ALsub) — s)oxeeFdschawe: Lolo ffl vy] prime: [a flab 1) Spe otAdmssion: Emergency] Panne] Day Care Matenin[] Nate Dateotdeen|o|0 lw vv ipcreveastaus )suusattmeot che Dichagetohone C] dschageoaoterhssal[] veceased] 1m) aldamed Amount DETAILS OF AILMENT DIAGNOSED (PRIMARY) MEE VN01077 1) ateofaémision: [0 [> Jl aNolo3s a TED 10 codes Description ®) IED TORS Description 9 Primary Diagnosis: i) Procedure i) Addonal Diagnosis iy Procedure? i) Comorbais LLL ip Proceduess LLL | W) Comores i) Dataset Procedcre © Presuthorigaton Obained: Yes] No] ©) Pe-Authoraation Number £) lfauthorzation by network hospital no obsained, gve reason sumption: i) finjry de to Substance abusefalcohel consumption, Test conducted to establish ths: Ys] Nef] esatach report) —w)edcoega es] No [] Hospitalization duetonjuy: Yes] No] ivfvesaive cause: Set-inficted:(] Road WaffeAccdent [] Substance abse/ alcohol ce 101035 iMpepored toPotce Yes ]NoL] — yAiene: pifrotreportedto police ge reason (LAIM DOCUMENTS -CHECK UST clam form dulysignea Hi tngeston pons orignal tre-puthorization request crmejuscinieeinsstigason report LE copyotPre-ruthoration ete [ocr reference sip forivestgatien 2 By copyet phot 1 card of paint vere by hospital es § 1 Hospital discharge summary Li trarmacybits g operation tear notes micrepor &Polce at 5 Hespital main bit L otigna death summary rom hospital where applicable Host! breakup i Li anyother lease specity [ADDITIONAL DETAILS INCASE OF NON NETWORK HOSPITAL (ONLY FIL IN CASE OF NON NETWORK HOSPITAL) 23) Address ofhospitl ary, state 1) Hosp PA i) thers DECLARATION BY THE HOSPITAL: (PLEASE READ VERY CAREFULLY) ‘Wie hereby declare thatthe nfarmation urished nthe Claim Forms ue and correct othe best af our know/edge andl. swe have made any fale and uniue statement, suppression or cnceament of any materia fact, or right to dai under this dam shall be ferfoted bate Pace Phone No ©) Registration nowt tate Code sentbeds|_| | feciiesavaableinbospta Jor: YesL_JNoL} — ijieuses LT NeL] I NolL93s NES Nou93s Signature and Sealof the Hosptal Authority‘GUIDANCE FOR FILLING CLAIM FORM PART (Tobe filed in by tel Tospial) ‘DATAELEMENT DESCRIPTION. FORMAT SECTION A- DETAILS OF HOSPITAL ‘Name of ospad Enver Rename of hospital Tame oT hospital E)Hospital 1D Enter D number ofthe hospal ‘As alocated by TPA ype of Hospital Thdicate whether in network or nan network hospital “Tickthe right option ‘Name of Treating doctor Enver te name of eating doctor Name ofdoctoriafull )Qualifcation Enter the qualification of treating Zocor abbreviations of educational ‘qualfcatione 1 Regatration Nowith sate code Ente he regsration no of eating doctor along with state code As allocated by the medical councilfinda Phene Ne Enter the phone no of decor Thelude STO code wth telephone number ‘SECTION B- DETAIIS OF THEPATIENT ADMITTED. a) Name ofthe patient Enter the name of hospital Name ofhospitain ull BYP Registration number Enter the nsurance provige region number ‘As aocated by the insurance pro Gender Tndicate Gender ofthe patient Tick Male or Female ‘se Ente age ofthe patient amber of years and month bate oT Enter date of admission Use dd-my format 1) Date of Admission Enter date of admission Use ed-meyy format ime Enter date of admission Use Rim format RYDae of Daharge Enter date of discharge Tie dd-my Tora Time Ener ume of ascharge Use Aim format 1) ype of Adan Tndicate type of admission of patient Tickthe right option Maternity Date of Delve rier Date of Delvery Irmateriy Tie dem format “Gavia Statue Enter Gravida status ifateriy Use standard format TT status atime ofiscarge Indicate satus ofpatent atime ofascharge Tiekthe night option ‘m)Total claimed amount Indicate the total claimed amount Tn rupees (Do not enterpavevalues) SECTION C- DETAILS OF ALMENT DIAGNOSED (PRIMARY) ID tale Primary Diagnosis Ente he [OD TO Cade and description af he primary agnor ‘Seandara Format and Open tet ‘Aadional agnosis Enter the ICD T0 Code and description ofthe additonal dlagneh ‘Standard Format and Open text ‘Co-morbites Ente the ICD_10 Code and description af the covmorbidites ‘Standard Format and Open text B) IED 1OPCS Procedure 1 Ee he ICD TOPS and description ofthe is procedure ‘Slandard Format and Open tet Procedure? Enter the ICD 10°CS and description ofthe second procedure ‘Standard Format and Open tex Procedure 3 Enter the ICD TOPCS and description ofthe third procedure “Standard Format and Open text Details of Proceaure Enter the details of the procedure ‘Opentext ©) Pre-authorzation obtained Indicate whether pre-authorzabon obtained Tick Yes oF Wo )Preauthorration Number Ente pre-authorization number Realorted by TR @) Fauthorzation By network Enter eason for not obtaining pre-authorization number ‘Open text hospital not obtained sie reason 1) Hospitalization due to injury Tadicate i hespaliaton due te uy TiekvesarWe Cause Indicate cause of uy Tecktie right option injury de to substance abuse] alcohal consumption, test, conducted to establish this Indicate whether test conducted Tick Yes No Medico Lege Traeate whether njunys medica Tega TekyerorNo Reported To Police Indicate whether police report was filed Teck Yes oF No FRM Enter Frstnformation report number 7s issued by police authors Tinot repared to paicegive reason | enter reason for not reporting to poice ‘Open Text SECTION D- CLAIM DOCUMENTS SUBMITTED-CHECKLIST Indicate which supporting documents are submited ‘SECTION E- DETAILS IN CASE OF NON NETWORK HOSPITAL Adare Enter he fll postal adres Tndlode Stren, Ciyand Pin Code ByPhone Na; nier he phone number of Rospial Trude STO code with telephone number “ORESiaaGn No wth Sate Code Ener the regration umber of he doctar slong with ‘As allocated by the Weal the sate code Council of ng “Hospital PAN Enter he permanent account number ‘Asalltted bythe Income Tax department ‘Number ofinpatient ede Enter te umber of patent beds Dias 1) Facies avaiable inthe Rospial Indicate facies available inthe hospital Tickthe rghtopiion, Fothers please specify SECTION F - DECLARATION BY THE HOSPITAL ead declaration careuly and meni jan dae (in dimmay format, place (open tex) andaign andtamp