PARTA

CLAIM 1ORM OR HALTH INSURANCE PO C SOHER THANINSURED TRAVEL ANID PERSONAL ACCIDENT

HH
HERTAGE Ht ALTY
TO
The issue of his BE iis0
Form
N BY THE
rot to De taken as an admission of liabilty

IRDAI License No. 008 (To be lled in block letters)

DETAILS OF PRIMARYINSURED
a) Policy No
c) Company/TPA ID No. MSUo17lolo47||o3
d) Name
alalo KUMakI
o)Address RaslT loloElSL DNAa
AL
City: l a l Z D A 3 A C I I
Pin Code 2 o | | | 2 o l K Phone No : b l s 3 2 l 1 7 l % l i B E m a i l ID
State: P UL
DETAILS OF INSURANCE HISTORY
Wo b) Date of commencement of first insurance without break:
a) Curently covered by any other Mediclaim/Health insurance: Yes

c) t yes, company name :

I LII Polcy No IIIII
? No
Sum Insured (Rs.) d) Have you been hospitalized in the last Yes
four years since Inception of the contract
e) Previously covered by any other Mediclaim/Health Insuraree Yos NO
Diagnosis
t yes, Company Name I U I.
DETAILS OFINSURED PERsON HOSPITALIZED:
Name
d) Dato of Birth: L o o l 2 ] 8 7
b) Gender Male Female )Age Years3UMonths
e) Relationship to Primary Insured, Set Spouse Child Father Mother Other(Please Spociy)
Occupation: Service Self Employed Homemaker Student Reired Other (Ploase Spocify)-
9) Adress (f diforent from above) HIA
ILL
City Stato:L
inCode L Phone No : L U I Email1D:I
DETAILS OF HOSPITALIZATION:
a) Name of Hospial where Admited oLFISPECIAiT|kosPiTALIII
jngle occupaney Twin sharing 3 or more beds per room|
b) Room Category occupled: Day care
c) Hospitatization due to: Injury llnes Maternity c)Date of injury/Date Discase first detected/Date of Delivery LI
e) Date of Addmission :

finjury give cause Selfinficted

Time OPm DnloofDischarge
Road Trafic Acident SuDstancoAbudeIAicoholConsumpion
0I02N
rMedico legal:
T zelela
No
wi) MLC Report&Police FIR attached YesNo J) Systom of Medicinee
) Reported to police : YesNo
DETAILS OF CLAIM
) Details of the treatment expenses caimed Claim Documonts Suom neck List
Claim Form Duly sig
.Pre-Hospitalization Expenses: Rs ii. Hospitalization Fxpcnses: Rs.
v. Health-Cneck up Cust:
77
Rs. Copy of the claim i n : i r , if anyy
. Post-Hospitalization Expenses: Rs.
v.Ambulance Charges Rs. LI vI. Others (cocse) Rs. L oo Hospital Main Bill

Total
RS Hospital Break-up Bi
vii. Pre-Hospitalization period: Days vii. Post-Hospltalizat:on period Days Hospital Bil Payment iecupt

Hospital Discharye S ry
b) Claim for Domiciliary Hospitalization Yes No (If yos. provide details in annexure) JPharmacy B
Operation TneareN:
c) Detais of Lump sum l cash benefit claimed: ECG
Hospital Daily Cash . Rs, ii. Surgical Cas. J D o c l o r ' s request ior

il. Crtical ilness Beneft Rs. iv. Convalescernce Investigatorn Ropo:s (nc ARIUSGHPE)
v. Pre/Post Hospitlaization 1, Doctor's Prascrpior

Lump sum benefit olal Others

DETAILS OF BILLS ENCLOSED:
SL No. BillNo,J Date Issued Dy TowarIS ,unt iRS)
Hospital Main Bill
Pre-hospItalzaton BM N0s.
FOsl-hospitaization Bill: Nos.

1K3| Pharmacy131s
2170o
2loo 700

DETAILS OF PRIMARY INSURED'S BANK ACcoUNT

a) PAN
c) Bank Name and Branch
d) Cheque/DD Payable details 9)FSC Code:
RA JVËR)
 DECLARATIONBY THE INSURED
hareby teelare th the itsrmtien tumisHed in Hi tim form s trse & oeret to tme my krewege and I made a ny alte or untrue reean
rormalrert ot any mntarial a t with s p e c t to q u e t y r e e k e in rMatn to t s c my i g h t to cf urtement h a be ofeteed d

TAinurane company toshek naneeeary medic irformeten #oeumens from any ospital/Vedfr Pratioer wo h1s atended on he personaq
matn [hpreby dertare that hue Inalutad al the bilts /rereipts tor the purpose o th 8 maIwl not be m a a y Supementary clainM ewcep' i e alizalinr
ntaih, any

Date
EDE ED Place Sigure of the Insured

GUIDANCE FOR FILLING CLAIM FORM -PART A (To be filcd in by theinsurod)

DESCRIPTION
DATA ELEMENT
SECTIONA- DE TAl S OF PRIMARY INSUE

Asallotted by he
) Policy No Enter the pol'oy numoer
b) Si No./Certificate No. Enter the social insurance number of the cer: e As allotted oy InC 0

number o sOCa. neath insurance schemne

A and
ompany TPA ID No. Enter the TPA D No L.icense n
d t n t e rn e u n a g e oi t n e policynolder
Name Surnam,a t
e) Address FEnter the 'ul: pos'a acdress Include stree, y
SECTION 8 DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Indicate wnetnc cently covered by another Tick Yes or No
Medidlaim/ Health Insurance? Aodiciam/ ticatnsura
srance
wse dd-tm_yy 'or
b) Date of Commencement of first insurance withoutbreak Enter the daie o' oom mencement ot tirst ns.. C
Company Name
Enter thefull name o theinsurance compa
Policy Enter the policy numer AS anoRCa y any
Enter the total sium insured as per the policy In rupees
Sum nsured
d) Have you been Hospitaiized in the las1 four years since Indicate whether hosp:talized in the last four years TICK Yes or No
iception ol the Contract
Date Enter thedate of hospitalization Uscr mm-y ua
Openlext
DiagnoSIs Enter the diagnosis details
e) PrevioUsly Coverd by any other ndicate whether previously covered by anotrer Tick Yos or No
Mediclaim/Health Insurance? mediclaim/Heain insurance
ompany Name Enter the full name of the insurance company Narne of the organ

SECTION C-DETAILS OF INSURED PERSON HOSPI'ALIZED

6e Enter the full name of the patient Suni/mC,tiSt t

0 enoer indicate Ge 1der o tre pauent

C) Age Entor age ofthe oatient NumbuT O yco

) Date ofBirth tnter Date of t5 n O patient US dG=nYy

e) Reiationship to primary Insurea indicate relatior'srp o Dalent wiln policyroluer se S

Occupation indicate OcCpat2 aent

9 Address Enter the full postal äadress incugO Sieet, C:y "
b Phone No LEnter the phone number of patient Inciude STD coue v
D E-mail 1D L Enter e-mail aacras of patient Complele eiialaG
SECTION D-DETAILS OF HOSPTALIZATK
6 Name o' Hospilal where admitted Enter the name ot nosptal Name o
D) Room calegory occupled indicale the roo Caegory occupied
C) Hospiualization due to indicate eason o' espitalizaluon
d) Date of injury / Date Diseasefirst detected Enter the relovant oate Uso du r-7Y ."
Date of DeliveryY

E DAE O 8dmisSion Enter dare o doSS on

ime Enter ume ol adnS> O
9 Daie of discharge Enter date of discnarg
Yime Enter time ol discharge Use nn:mm armal
Indicate cause of injury
D inury give cause
f Medicolegal indicate whether injury in medico legal lick Yes or

Reponled lo Police Indicate whethor policereport was filed iC Yes

MLC Repart &PoliceFIR attacheed Indicate whether MiC report and Police atc
WSystenm DiMsdiGine Enter the systern ofl medicine followed in t'e e Baert_Opo A
SECTION E-DETAILS OFCLAIM
) Detalsuf Treainment Expenses Enter the arnount clä "n.ed as trealnent ex pces
CHam tarGumiGilaryHOsplalzalon noicale Wretrnor cidft iS TOr dornicHiary ti9S :1

9 Detals of Lumpbumicash benefit claimed Enter the amouft Gia"ned as lump sum Jcasn un

Caim Documenis Submitied-Check List Indicale wnhcr support/ng documentsare sut

SECTION F DETAILS OF BLLS ENCLOSt
irndicale Wt UCII DlIS ale elidobB0 win the althounts in fupebs
SECTION G DETAILSOFPRIMARY INSUREDSb CcouNt
PAN it

D)AUDuNt Nurmpe
D Bana Naits ard branth
d) CheyuelDD payatulte detalls

6) FSC Cud6
SECTION H DECIARATION BY THE IAS:

Read decdaraton caretuly and mention date (in dd m yy format). pace (open teat) ar d sgn.