BAJAJ ALLIANZ GENERAL INSURANCE COMPANY

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952/954, Appasaheb Marathe Marg,, █ █ ▀█▄█▄ ▀ ██ ▀ ▄ █ ▄█
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Prabhadevi, Mumbai-400025

DOMICILLIARY CLAIM FORM (NON HOSPITALIZATION FORM)

Claim form No: 24C01LTIM007918 (for office use only)

1.Emp No 61069978 Grade M5

2.Company Name LTIMINDTREE. Branch CHENNAI

3.Employee Name ABHISHEK SARMA Age 37.39
4.Name of the Patient Varenyam K Sarma Age 1
5.Relationship CHILD1 Cost Centre 212NX

6.Duration of Treatment 20-Nov-2023 To 24-Dec-2023

From
7.Currency Type INDIAN RUPEE
Component Nature Of illness Claimed Amount Approved Amount
DOMICILIARY Constipation 500.000 500.000
DOMICILIARY Constipation 216.000 216.000
DOMICILIARY Vaccination 500.000 500.000
DOMICILIARY Vaccination 1930.000 1930.000

Total 3146.000 3146.000

In support of the claim I am attaching :

• Original detail bills with Receipt of payments ( Hospital / Clinic /Medical /Surgical Store /
Labs & Diagnostic Centre )
• Supportive - Doctor's Latest Prescription / Consultation papers mentioning Diagnosis /
Complaints & Procedure details.
• Original Investigation Reports ( Pathological , Radiological etc. )

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have
made or shall make any false or untrue statement suppression or concealment my right to claim
reimbursement of the said expenses shall be absolutely forfeited. I further declare that in respect
of the above treatment no benefits are admissible under any other Medical Scheme of insurance.
I consent and authorise the insurers to seek medical information from any Hospital / Medical
Practitioner who has at any time attended concerning the claim.
Signature of the Claimant

25-Dec-2023

Note: Please submit the claim documents to nearest scanning centre.

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