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HDFC ERGO General insurance Company Limited CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN ‘TRAVEL AND PERSONAL ACCIDENT CLAIM FORM — PART A Tote atin teint ELRT TU Lote one wena an adr aay ASTM, s£cr0A- DEALS OF mA HSURED se = geass Rote ig, ZEOS 2088 1918 G03 AMO none: VERMA Niaay kumar i RB-40, NEHRU Enclave, KALeAS oe NEW NELHY = Neat moe Woo MOTRIN S} ewe CEL IM pYRe (went) bw scomow- sets or msuRates Wsron? Scamearcomst my cermeccan acme: Yes hoc ont a a 8 Ys, Congary Hare: Petey noe ‘Sum reo ah a Weveyeu tanned tele er yearshenteapton othe ene!’ Yen No Das agr: )Prevouy cone by ary ser edninetinemvarer: Yes ND 1 9, company Nam ‘SECTION ¢-DETAILS OF SURED PERSON HoSPrTALISED 2) on: veemy waay Kumar RNIN sur spams carat | Matar erent Somer CO. ITAS.. se Be ‘Somsbeve) SIME AC shove Gen: Naie Female a) nip: Seve Sehempns Honemaar on Red ter Peete RU WE om: Sate Prone: pone ‘neta a: Demi: ‘SECTION D-DETALS OF HOSPTTALZATION anne terion } CARE Eye WaerIAL Difoon cage ec: Oasee | 7 SeOsrashey —-TanStowy Seema bac paren jHowptcon de: non” Ny Ney =) Dan oly Dt fem it tc fly VOaecteameson — AFOK AOLR om OL ZY cpomectaatawes {OL IOD2 — MAB“ 25 \) eaeysrecnes Sefiined Reed Tatisscaet —Sibcrcesbuns hel Cenaumpon lw 1) Mascot vee Ao ‘nReprestogcnet Yor 0 NLC Raper ce Rabat? You NS 2 Sent ee ‘stenowe- pewansor cua 2) ts teint iene cra ‘ram Secor Sabie: Chsk Li nPretiotaain Boece Re 2 Hewtteston eres yoda oes a era ‘i Fennptenon eno Re tateemcnecpcomt Ra. appt rate ee Con wAmodoca Canes ote ee) m sonata oF ae a oxen Up at aretonientotet Oe or stesiatnhese Soe | eeresoee Dawe Suman tele oomcan/Heptaton: Yee os pean ro tte naman Pmt eee Peas spt mca = 9 someon re |e Sotalietet te ewan ee perenne wore fe .) == Text Re eee Gee) Soper Gey ate tec page ta See oe ‘Gear i Regs Cops Ges VOR Ts VP, taaay sans HT Pn Chaps ba DL Ge Sena Po SP i a es ena HOE ene 02 a fat na ac GND agg | usage IRDAL Reg NO. 108. ‘SECTION DEMIS. OF BEL ENCLOSED sn ae. ome ea By erst meant) SETTING DETAR OF me SENS Mabe ACCOUNT nat BAB PY LUO Account Rambo Pajtte ete cre Oo: “IFSC cose nc: Totcessartomamenmerercm ELS SAR RET vey wrong enc rem samt nate neo FESS otea cata an mpage eee tc ie SECON W~ DECLARATION BY THE SURED ‘erty des hath ramaten arisen bis cn mnt &.coved tebe omy kaelecon andl Need aye rv Samer. soaeti o _cechnertt any teria ge eae acai ran totum, salocaam rasa lb ans cesta ones Terese ‘Seman sek nce medal rerio ocr tm ay Feat! Made “metang ni as sled one tors eas pres oe ‘Serb overcentre epuponn ste dom atl aise naiangeny seem Samo seseooe regalo - om a Aipert inom CSAOSNCETORFEINGCLAMFOR=PARTA,T De tiny ee onasimiecr rosuat Se=nOWA- DEMS Or BU SED orate caer fesse nec npn) Behe coset a Exrryootivorcenrtestecesam — MacntySecomnen conan TPAD Ha — iam easy OA seca name fr bts te pepe noe Pe ate one ria Carmona poate sits competi szcnowe, DETALS Or RSURANCE HETORY mae Medco Hester ia Yocom inthemrevibtmat — Careesncfemmenementittasune nem et Sloman Sraentimn tetera teectuc operat nt Payne Enc teneyante recat pore ry Satan Enc tonearm angry ia neater ein i? ‘un wente tema ators oun Cre cart teen Uneanyy ect Soe enw age ae crates lone yy te Med ta ce pe oe yer Seine ae isamnamsss ae Encrbet cael nwo cone sent omni secnow.o- DOr ne PON OSTA hare te tseame cere sera rae te ane Sonar Samnomorcteepeme Sacro Shoe Evecare ‘te ear ie ooo Exomatocrtet loamy net Src pays cena pen or Faonpanpn torsos pes apeenrion Tekswapecrsn fone oe oun Eacacapeens Homaenabysneretny Seen Ene eepmemrener ep Simemomwnumbmennte 5 Seman Ecrommeaien ine Sno vente 4 ccna” bent cr noSPALaroN 2) hee tht ond connects semen : Samegyeme fos eeanyonrny Tarteuptopen i Seca Peerieieaprentinng Taner ' Slnssttjnte ema ft eee Decay ronan Unainmey tnt : ‘omc pesaneceoe Us comnytmet i ime cameseman tne : domeatdeae Sow aa ane Parser i ote careedamey Semone i Sy can ‘scm cectay Sexpwrccrn nt Nom copy metters Tene tomate ‘acne pc pa at meee icra rae rane Soccweowincupetonranricmies Tanvesrt ojo Sacmsormnctmcie tier pint per Tecnowepeasorciae jot met pes oarteanect cand s'imactngeeet fangs Dot pan es Syne Dka nn nacmecna canttranayiazcan Tater Sonate cea et Eceteccoctsanctaipericca test’ ergs Donne tes cam ems neem et Sciwcanpenyaomenscremnt — tartwenonn nea when een wt anounia noes ‘URGE en Cape Ole NPP 15 Boao Pera 01 Paling Casas a RUGR a ee e ane Pat ho a aE Meo 052 Rr 282750 Deltona wees TRDAT Repo. 125. 2

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