IRDA Registration No.

l 29

a) Policy No

b) Sl. No/ Certificate No :

c) Company/ TPA lD No :

d) Name:

e) Address :

Phone No :

a) Cunently covered by any other Mediclaim / Health lnsurance , yes *o

l--l E
b)Dateofcommencementoffintlnsurancewitroutbreak:
tr tr tr tr tr I
(Copies of Policies to be attached)

c) lf yes, company Name :

Policy No :

Sum lnsured (Rs.) :

d) Have you been hospitalized in tre last 4 yearse

l-l Ves
I *o

Diagnosis :

e) Previously covered by any other Mediclaim/ Health lnsurance :

f) lf yes, company Name :

a) Name:

b) Gender : Mab
[-l Femab
l-l c)Ase :Years
[l[ uonttr
IE ol Date of Birth,
EE trI trI
e)RetationshiptoPrimarylnsured: ser l-l spouse
l-l chird l-l rrr'.r I r'lon.r. f] other tr
(Please Specify) :

f)occupation: service [-l seffEmploved l-l Homemarer [-l student I netreo I other I

State:

a) Name of Hospital where Admitted :

b) Room Category Occupied : Day care

l-l singte Occupancy
[---l r*in Sharing ! s or more beds per room
l-l
c) Hospitalization due to : lnjury
tr lllness tr Maternity

d) Date of lnjury / Date Disease first detected / Date of Deliveu

E
e)DateofAdmission,
E tr t] tr tr tr
g)DateofDischarse,
I tr tr tr t] tr
l) lf lnjury give cause : Self lnflicted
l-l Road Traffc AcciOent
l-l Substance Abuse / Alcohol Consumption
[-l
a) Details of the treatment expenses claimed Claim Documents Submitted - Check List:
l. Pre -hospitaliztion Expenses : Rs
! CUi, Form Duly Signed

ii. Hospitalization Expenses: Rs

aou
iii. Posthospitalization Expenses : Rs E of the claim intimation

iv. Health- Check up Cost :

! HospitalMain Bill

v. Ambulance Charges :

! Hospital Break-up Bill

I Hospital Bill Payment Receipt

vii. Pre-hospitalization period : days

viii. Post-hospitalization period : days

I Hosnital Discharge Summary

l-l Pharmacy Bill

(lf yes, povide details in annexure)

c) Details of Lump sum / cash benefit claimed :

l-l Operation Theatre Notes

v. Pre/ Posl hospitalization Lump sum banefit: Rs

Towards Amount (Rs)

Hospital Main Bill

Pharmary Bills

b) BankAccount Number:

c) Bank Name and Branch :

d) Cheque/ DD Payable details :

e) IFSC Code : ....................

 I hereby declare that the infomation fumished in this claim fom is true & corect to the best of my knowledge and belief. lf I have made any false or untrue statement,
suppression or @ncealmenl of any matsial fact, my right to claim reimbuEemsnt shall be forfeited. I also @nsenl E authorize TPA / insurance @mpany, to ssek nsessary
mediel inlomation / d@uments from any hospital / Medical Practitioner who has attended on the pe6on against whom this claim is made. I hereby declare that I have
included all the bills / re@ipls tor the purpose of this claim & that I will not be making any supplementary claim ex@pt the prelpost-hospitaliation claim, if any.

a) Policy No. Enter the policy number As allotted by the insurance company
Enter the s@ial insuran@ number or the ertificate number of
s@ial health insuran@ scheme As allofted by the organization

c) CompanyTPA lD No. License number as allotted by IRDA and

orinted in TPA d@uments.
d) Name Enter lhe full name ol the policyholder Sumame, FiBt name, Middle nam€
e) Address Enter the full postal address

a) Curently @vered by any olher Modiclaim / Health lndicate whether curently covered by another Mediclaim /
Insuran6? Health lnsumnc
b) Date ofCommencement ofliEt lnsuran€ without break Enter the date of @mmencement of fiEi insurane
c) Company Name Enter the full name of the insuran@ company Name of the organization in full
Policy No. Enter the policy number As allotted by the insurance @mpany
Sum lnsured Enter the total sum insured as per the policy ln rupees
d) Have you been Hospitalized in the last 4 yeaE lndicate whether hospitalized in the lasl 4 years Tick Yes or No
Enter the date of hospitalization Use mm-yy fomat
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim/ Health lndicate whsther previously @vered by anolher Mediclaim /
lnsuranc6? Health lnsuran@ Tick Yes or No
f) Company Name Enter the full name of lhe insurance company Name of the organization in full

a) Nams Enter the full name of the patient Sumame, FiEt name, Middle name
b) Gender lndicata Gender of the patient Tick Male or Female
Enter age ot the patient Number of y€aE and months

e) Relationship to primary lnsurod Tick the right option. lf otheE, please specify.
f) O@upation lndicate @cupation of patient
g) Address Enter the full postal address lnclude Street, City and Pin Code
h) Phone No Enter the phone number of patient lnclude STD code with telephone number
,) E-mail lD Enter e-mail address of patient Complete e-mail address

a) Name of Hospital wher€ admitted Enter the name of hospital

b) Room etegoryoccupiod lndicate the r@m caiegory occupied
c) Hospitaliation due to lndicate reason of hospitalization
Enter the relevant date Use dd-mm-yy fomat
e) Date o, admi$ion Enter date of admission Use dd-mm-yy fomat
Enter time of admission Use hh:mm fomat
9) Date ot discharge Enter date of discharge Use dd-mm-yy fomal
Enter tims of discharge Use hh:mm fomat
r) lf lnjury give @us lndicate @use of iniury
lndicate whether iniury is medi@ legal Tick YEs or No
lndicate whethe. police report ms liled Tick Yes or No
MLC Report & Police FIR attached Tick Yes or No
l) System of Medicine Enter the system of medicine followed in treating the patient Open Text

a) Dotails of Treatment Expen$s Enter the amount claimed as treatmenl expenses ln rupees (Do nol enter paise values)
lndicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details ot Lump sum/ 6sh benefit claimed Enter the amount claimed as lump sum/ €sh benefit ln rupeos (Do not enter paise values)
d) Claim Documents Submitted-Check List lndicate which supporting documents are submittsd Tick lhe right option

lndi@te which bills are snclosed with the amounts in rupees

Enter the pemanenl ac@unt number As allotted by the ln@me Tax department
Enter the bank accounl number
c) Bank NamE and BEnch Enter the bank name along with the branch
Enter the name ol ths beneficiary th6 cheque/ DO should be
d) Cheque/ OD payable details
made out to Name of the individuay organiation in full

e) IFSC Code

Read declaration carefully and mention date (in dd:mm:yy fomat place (open text) and sign.
 lROA Registration No.129
The issue of this form is not to b€ taken as an admission of liability. Please include the original preauthorization request form in lieu of PART A

c)Type of Hospital : Network Non Network (lf non network fill section E)

f) Registration No. with State Code :

a) Name of the Patient :

b) lP Registration Number: ..................... c) Gender: Mab l-l Female

i]
g)Time : ..................... d)Age :Years[ [ Months'E I I Date of Admission :
[ tr tr tr tr tr
e) Date of Birth'E E t] tr tr tr l) Time :
tl tl tl I h) Date of Discharse,
f] fl I I tr tr
Planned DayCare
tr Matemity
IOIMaternity
ii) Gravida Status :

l) Status at time of discharge : Discharge to home

tr Discharge to another hospitd
[l Deceased tr

Description

Description

Procedure

Procedure

iii. Procedure 3
d) Pre-authorization obtained :

f) lf authorization by network hospital not obtained, give reason :

ii. lf lnjury due to Substance abuse/ alcohol consumption, Test Conducted to establish this :

E t r E *. (lf Yes, athch reports)

iv. Reported to Police : I r* E *.

vi lf not reported to plice give reason :

Claim Form duly signed lnvestigation reports

Original Pre-authorization request CT/MR/USG/H PE investigation reports

Copy of the Pre-authorization appoval letter Docto/s reference slip for investigation

Copy of photo lD card of patient verified by hospital ECG

Hospital Discharge summary Pharmacy bills

0peration Theatre notes MLC report& Police FIR

Hospital main bill Original death summary from hospitalwhere applicable

Hospital break-up bill Any other, please specify

a)Address of the Hospital :

State :

c) Regishation No :

d) PAN : e) Number of lnpatient beds :

f)Facilities avaitabte in the hospitat: t. or

' I vrr E *o ii. tcU : I v., I *o
DECLARATTON BYINSURED (PLEASE READVERYCAREFULLY)

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. lf
I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement
shall be forfeited. I also consent & authorize TPII/ insurance company, to seek necessary medical information / documents from
any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I
have included all the bills / receipts for the purpose of this claim & that will not be making any supplementary claim except the
pre/post hospitalization claim, if any.

Place :

Signature of the lnsured :

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY}

We hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief . lf we
have made anyfalse or untrue statement, suppression orconcealment of any materialfact, our rightto claim underthis claim shall
be forfeited. The signature of the insured is taken on this form afterClaim Form B isfully filled up by us.

Signature and Seal of the Hospital Authority : .....................

(IMPORTANT: PLEASE TURiI OVER)

 Not to be Faxed I Scanned

Enter lhe name of hospital Name of hospital in full

Enter lD number of hospital
c) Type ofHospital lndicate whether ln network or non network nospital
d) Name of treating doctor Enter the name ofthe treating doctor

Enter the qualifications of the treating doctor Abbfeviations of educational qualifications

Enter the rogistration number of the doctor along with th6 state
As allocated by the Medical Council of lndia
code

S) Phone No. Enter the phone number of doctor lnclude STD code with telephone number

a) Name of Palient Enter the name of hospital Name of hospital in full

b) lP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender lndicate Gender of the patient Tick Male or Female
Enter age of the patlent Number of years and months
Enter date of admission Use dd-mm-yyformat
Enter time of admission Use hh:mm format
g) Date of Discharge Enter date of discharge Use dd-mm-yy format
Enter time of discharge Us6 hh:mm format
i) Type of Admission lndicate type of admission of patient Tick the rEht option
j) lf Matemity

Enter Date of Delivery if maternity Use dd-mm-yy format

Enler Gravida status if maternity Use standard format
k) Status at time of discharge lndicate status of patient at time of discharge Tick the right option

Enter the ICD 10 Code and d€scription of the pdmary

Primary Diagnosis Standard Format and Open text
diaqnosis
Additional Diagnosis Standard Format and Open text

Procedure 1
Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
lndicate whether pres€nt ailment is a complication of some pre-
c) Present Ailment is a Complication of PED
existino disease
d) Pre-authorizationobtained lndicate whether pre-authorization obtained
e) Pre-authorizationNumber Enter pre-authorization number

Enler reason for not obtaining pre-authorization number Open text

g) Hospitalization dueto injury lndicate if hospitalization is due to injury

Cause lndicate cause of iniury Tick the right option
lf injury due to substance abuse/almhol consumption,
lndicate whether test conducted Tick Yes or No
test conducted to establish this
Medico Legal lndicate whether iniury is medico legal

lndicate whether police report was filed Tick Yes or No

Enter first information report number As issued by police authorities
lf not reported to police, give reason Enter reason for not reponing to police Open Text

lndicate which supporting documenls are submitted

a) Address Enter th€ full postal address

b) Phone No Enter the phone number of hospital lnclude STD code with telephone number
Enter the registration number of patient As allocated by the Hospital
Enter the permanent account number As allotted by the lncome Tax deparlment
e) Numberof lnpatient Beds Enter the number of inpatient beds
f) Facilities available in the hospital lndicate facilities available in the hospital Tick the righl option. lf others, please specify

Read declaration carefully and mention date (in dd:mm:yy format), place (open tex) and sign.

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp