Tracking No.

: H010520220223372705

Employee no.: 2413663 / 5089234467 | Contact no.: 7620915912 | vshambhar83@gmail.com

Claimant/Patient
Ojasvi vivek shambharkar

Bank Details

Account holder name A/c no. IFSC code

Vivek Balaji Shambharkar 31*******93 S*********8

Bank name STATE BANK OF INDIA

Bank address OPP.**************************************APUR

Claim Details

Nature of illness Duration of illness Total amount

Severe infection in body. Diarrhea. Lactose 4 Day(s) 30466
intolerance.

Name of the hospital Hospital location

Trinity children's hospital Pugliya nagar, near janata college, civil line,
Chandrapur.

Admission date Discharge date Date of claim submission

17-Mar-2022 21-Mar-2022 01 May 2022

Reason for late claim submission

N/A

Reason for non-availing cashless facility

N/A

Documents Which Are Submited

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, suppressed or concealed any material fact, my right to claim
reimbursement shall be forfeited. I also consent & authorize the TPA or the insurance company to seek necessary
medical information from any hospital / Medical Practitioner who has attended to the person for whom the 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 that of Post - hospitalisation claim, if any.

Employee Signature
Date : 01 May 2022
UNDERTAKING BY THE PATIENT/INSURED

Patient Name Ojasvi vivek shambharkar

Relationship with Primary Beneficiary Daughter
Name of the Hospital Trinity children's hospital
Date of Admission 17-Mar-2022

The patient has been admitted for Severe infection in body. Diarrhea. Lactose intolerance. (Provisional diagnosis) .

I have read and understood the policy terms & conditions including the room rent eligibility and other sub-limits as defined under the policy.

I hereby undertake to bear and pay all non-admissible expenses, expenses not related to hospitalised ailment, expenses arising due to availing
higher room rent/ category over and above my policy limit, all expenses which are over and above the reasonable, customary and necessary
expenses for treatment of this ailment and any other expenses which are not admissible and are excluded in the policy. I understand and agree that
the above mentioned expenses shall not be reimbursed by the Insurance Company and shall be paid to the Hospital by me.

Date Signature of the patient/patient's relative

Name:
Date of Submission
Relationship: