CLAIM FORM - PART A. TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability
|
|
- Madeline Powell
- 5 years ago
- Views:
Transcription
1 CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The ssue of ths Form s not to be tken s n dmsson of lblty SECTION A - DETAILS OF PRIMARY INSURED c d e Polcy No Compny/TPA ID No Nme Address b Sl. No/Certfcte No: Cty/Stte Phone no Eml ID Pncode SECTION B - DETAILS OF INSURANCE HISTORY Currently covered by ny other Medclm/Helth nsurnce YES No b Dte of commencement of frst nsurnce wthout brek d f c If Yes, Compny Nme Polcy No. Sum Insured Hve you been hosptlzed n the lst four yers snce ncepton of the contrct Dgnoss If yes, Compny Nme e YES No Dte Prevously covered by ny other Medclm/Helth nsurnce YES No SECTION C - DETAILS OF INSURED PERSON HOSPITALISED g Address (f dfferent from bove) h Telephone No Moble No j Nme b Gender Mle Femle c Age Yers Y Y Months M M d Dte of Brth e Reltonshp to Prmry Insured Self Spouse Chld Fther Mother Other (Plese Specfy) f Occupton Servce Self-employed Homemker Student Retred Other (Plese Specfy) Eml ID Nme of the Hosptl where dmtted SECTION D - DETAILS OF HOSPITALISATION b Room Ctegory occuped Dycre Sngle Occupncy Twn Shrng 3 or more beds per room c Hosptllston due to Illness Injury Mternty d Dte of Injury/Dte of dsese frst detected/dte of delvery e Dte of dmsson f Tme H H M M g Dte of dschrge h Tme H H M M If njury, gve cuse Self-Inflcted Rod Trffc Accdent Substnce Abuse Alcohol Consumpton If Medco legl YES No Reported to polce? YES No MLC Report, & Polce FIR ttched? YES No j System of medcne Detls of the tretment expenses clmed Pre-hosptlston Expenses Post-hosptlston Expenses v Ambulnce Chrges Hosptlston Expenses v Helth-Check up Cost v Others (code) v Pre-hosptlston Perod dys v Post - hosptlston Perod dys Clm for Domclry Hosptlzton YES No (f yes, plese provde detls n nnexure) b Detls of Lumpsum/csh beneft clmed: Hosptl Dly Csh Crtcl Illness Beneft v Pre/Post hosptlston lumpsum beneft Clm Documents Submtted - Check Lst: Clm Form duly flled nd sgned Hosptl Mn Bll Hosptl Bll Pyment Recept Phrmcy Bll ECG Investgton Reports (Includng CT, MRI/USG/HPE) Others SECTION E - DETAILS OF CLAIM Surgcl Csh v Convlescence v Others Totl - Totl Copy of ntmton letter, f ny Hosptl Brek Up bll Hosptl Dschrge Summry Operton Thetre Notes Doctor s Request for Investgton Doctor s Prescrpton Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
2 SECTION - F DETAILS OF BILLS ENCLOSED S. No. Bll No. Dte Issued by Towrds Amount () D D M M Y Y Hosptl Mn Bll Pre Hosptlston Blls (.Nos) Post Hosptlston Blls ( Nos) Phrmcy Blls SECTION - G DETAILS OF PRIMARY INSURED S BANK ACCOUNT PAN b Account Number c d e f Bnk Nme/Brnch Pyble detls: Cheque/DD IFSC Code MICR No *plese ttch cncelled cheque pertnng to the sme *plese ttch cncelled cheque pertnng to the sme Note: It s greed tht the Polcyholder/Clmnt wll ntmte n wrtng to DHFL Generl Insurnce Lmted. bout ny chnge n bnk ccount detls. SECTION H - DECLARATION BY THE INSURED I hereby declre tht the nformton furnshed n ths clm form s true & correct to the best of my knowledge nd belef. If I hve mde ny flse or untrue sttement, suppresson or concelment of ny mterl fct wth respect to questons sked n relton to ths clm, my rght to clm rembursement shll be forfeted. I lso consent & uthorze TPA / nsurnce compny, to seek necessry medcl nformton/documents from ny hosptl/medcl Prcttoner who hs ttended on the person gnst whom ths clm s mde. I hereby declre tht I hve ncluded ll the blls/recepts for the purpose of ths clm & tht I wll not be mkng ny supplementry clm except the pre/post-hosptlzton clm, f ny. Dte: Plce: Sgnture of Insured Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
3 GUIDANCE FOR FILLING CLAIM FORM - PART A (To be flled n by the nsured) DATA ELEMENT DESCRIPTION FORMAT SECTION A - DETAILS OF PRIMARY INSURED ) Polcy No. b) SI. No/Certfcte No. c) Compny TPA ID No. d) Nme e) Address Enter the polcy number Enter the socl nsurnce number or the certfcte number of socl helth nsurnce scheme Enter the TPA ID No Enter the full nme of the polcyholder Enter the full postl ddress As llotted by the nsurnce compny As llotted by the orgnzton Lcense number s llotted by IRDA nd prnted n TPA documents. Surnme, Frst nme, Mddle nme Include Street, Cty nd Pn Code SECTION B - DETAILS OF INSURANCE HISTORY ) Currently covered by ny other Medclm/ Helth Insurnce? b) Dte of Commencement of frst Insurnce wthout brek c) Compny Nme Polcy No. Sum Insured d) Hve you been Hosptlzed n the lst four yers snce ncepton of the contrct Dte Dgnoss e) Prevously Covered by ny other Medclm/ Helth Insurnce? f) Compny Nme Indcte whether currently covered by nother Medclm/ Helth Insurnce Enter the dte of commencement of frst nsurnce Enter the full nme of the nsurnce compny Enter the polcy number Enter the totl sum nsured s per the polcy Indcte whether hosptlzed n the lst four yers Enter the dte of hosptlzton Enter the dgnoss detls Indcte whether prevously covered by nother Medclm/ Helth Insurnce Enter the full nme of the nsurnce compny Tck Yes or No Use dd-mm-yy formt Nme of the orgnzton n full As llotted by the nsurnce compny In rupees Tck Yes or No Use mm-yy formt Open Text Tck Yes or No Nme of the orgnzton n full SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED ) Nme b) Gender c) Age d) Dte of Brth e) Reltonshp to prmry Insured f) Occupton g) Address h) Phone No ) E-ml ID Enter the full nme of the ptent Indcte Gender of the ptent Enter ge of the ptent Enter Dte of Brth of ptent Indcte reltonshp of ptent wth polcyholder Indcte occupton of ptent Enter the full postl ddress Enter the phone number of ptent Enter e-ml ddress of ptent Surnme, Frst nme, Mddle nme Tck Mle or Femle Number of yers nd months Use dd-mm-yy formt Tck the rght opton. If others, plese specfy. Tck the rght opton. If others, plese specfy. Include Street, Cty nd Pn Code Include STD code wth telephone number Complete e-ml ddress SECTION D - DETAILS OF HOSPITALIZATION ) Nme of Hosptl where dmtted b) Room ctegory occuped c) Hosptlzton due to Enter the nme of hosptl Indcte the room ctegory occuped Indcte reson of hosptlzton Nme of hosptl n full Tck the rght opton Tck the rght opton d) Dte of Injury/Dte Dsese frst detected/ Dte of Delvery e) Dte of dmsson f) Tme g) Dte of dschrge h) Tme ) If Injury gve cuse If Medco legl Reported to Polce MLC Report & Polce FIR ttched j) System of Medcne Enter the relevnt dte Enter dte of dmsson Enter tme of dmsson Enter dte of dschrge Enter tme of dschrge Indcte cuse of njury Indcte whether njury s medco legl Indcte whether polce report ws fled Indcte whether MLC report nd Polce FIR ttched Enter the system of medcne followed n tretng the ptent Use dd-mm-yy formt Use dd-mm-yy formt Use hh:mm formt Use dd-mm-yy formt Use hh:mm formt Tck the rght opton Tck Yes or No Tck Yes or No Tck Yes or No Open Text SECTION E - DETAILS OF CLAIM ) Detls of Tretment Expenses b) Clm for Domclry Hosptlzton c) Detls of Lump sum/csh beneft clmed d) Clm Documents Submtted-Check Lst Enter the mount clmed s tretment expenses Indcte whether clm s for domclry hosptlzton Enter the mount clmed s lump sum/csh beneft Indcte whch supportng documents re submtted In rupees (Do not enter pse vlues) Tck Yes or No In rupees (Do not enter pse vlues) Tck the rght opton SECTION F - DETAILS OF BILLS ENCLOSED Indcte whch blls re enclosed wth the mounts n rupees Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
4 DATA ELEMENT DESCRIPTION SECTION G - DETAILS OF PRIMARY INSURED S BANK ACCOUNT ) PAN Enter the permnent ccount number b) Account Number Enter the bnk ccount number c) Bnk Nme nd Brnch Enter the bnk nme long wth the brnch d) Cheque/DD pyble detls Enter the nme of the benefcry the cheque/dd should be mde out to e) IFSC Code Enter the IFSC code of the bnk brnch SECTION H - DECLARATION BY THE INSURED Red declrton crefully nd menton dte (n dd:mm:yy formt), plce (open text) nd sgn. FORMAT As llotted by the Income Tx Deprtment As llotted by the bnk Nme of the Bnk n full Nme of the ndvdul/orgnzton n full IFSC code of the bnk brnch n full Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
5 CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The ssue of ths Form s not to be tken s n dmsson of lblty Plese nclude the orgnl preuthorzton request form n leu of PART A SECTION A - DETAILS OF HOSPITAL Nme of the Hosptl b Hosptl ID c Type of Hosptl Network Non Network (If non network fll form secton E) d Nme of the tretng Doctor e Qulfcton e Regstrton No wth stte Code SECTION B - DETAILS OF PATIENT ADMITTED g Phone No: Nme of the ptent b IP Regstrton Number c Gender Mle Femle d Age Yers Y Y Months M M e h Dte of Brth f Dte of Admsson g Tme of Admsson Y Y M M Dte of Dschrge Tme of Dschrge H H M M j Type of Admsson Emergency Plnned Dycre Mternty Grvd Sttus l Sttus t tme of dschrge Totl Clmed Amount Dschrged to Home k If Mternty SECTION C - DETAILS OF AILMENTS DIAGNISED (PRIMARY) Dte of Delvery Dschrged to nother Hosptl Decesed ICD 10 Code Prmry Dgnoss Addtonl Dgnoss Co-morbdtes Clm form duly flled nd sgned Orgnl Pre uthorzton Request Copy of Pre-uthorzton pprovl Letter Copy of photo ID crd of ptent verfed by Hosptl Hosptl Dschrge Summry Operton Thetre Notes Hosptl Mn Bll Hosptl brek up Bll Address of the Hosptl SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECKLIST Investgton reports CT/MRI/USG/HPE nvestgton Report Doctor s reference slp for Investgton ECG Phrmcy Blls MLC Report & Polce FIR Orgnl deth summry from hosptl where pplcble Any other, Pl specfy SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL (Only fll n cse of Non Network Hosptl) b Phone No: c Regstrton no wth Stte Code d Hosptl PAN e No of In-ptent Beds f Fcltes vlble n Hosptl OT YES No ICU YES No Others SECTION F - DECLARATION BY THE INSURED I hereby declre tht the nformton furnshed n ths clm form s true & correct to the best of my knowledge nd belef. If I hve mde ny flse or untrue sttement, suppresson or concelment of ny mterl fct, my rght to clm rembursement shll be forfeted. I lso consent & uthorze TPA/nsurnce compny, to seek necessry medcl nformton/documents from ny hosptl/medcl Prcttoner who hs ttended on the person gnst whom ths clm s mde. I hereby declre tht I hve ncluded ll the blls/recept for the purpose of ths clm & tht I wll not be mkng ny supplementry clm expect the pre/post hosptlzton clm, f ny, Dte: Plce: Descrpton Procedure 1 Procedure 2 Procedure 3 c Present lment s complcton of PED? YES No If Yes, specfy detls b ICD 10 Code d Pre-uthorzton obtned YES No e Pre-uthorzton No f If uthorzton by network hosptl not obtned, gve reson g Hosptlston due to Injury YES No If yes, gve cuse Sgnture of the Insured Detls of the Procedure Self nflcted? YES No Rod Trffc Accdent YES No Substnce Abuse/Alcohol Consumpton YES No If Injury due to Substnce buse/lcohol consumpton, Test Conducted to estblsh ths: YES No (If yes, ttch reports) Medco Legl YES No v Reported to Polce YES No v FIR No YES No v If not reported to Polce gve resons Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
6 SECTION G - DECLARATION BY HOSPITAL We hereby declre tht the nformton furnshed n ths Clm Form s true & correct to the best of our knowledge nd belef. If we hve mde ny flse or untrue sttement, suppresson or concelment of ny mterl fct, our rght to clm under ths clm shll be forfeted. Dte: Plce: Tretng Doctor Sgnture nd sel of the Hosptl Authorty Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
7 GUIDANCE FOR FILLING CLAIM FORM - PART B (To be flled n by the hosptl) DATA ELEMENT DESCRIPTION FORMAT SECTION A - DETAILS OF HOSPITAL ) Nme of Hosptl b) Hosptl ID c) Type of Hosptl d) Nme of tretng doctor e) Qulfcton f) Regstrton No. wth Stte Code g) Phone No. ) Nme of Ptent b) IP Regstrton Number c) Gender d) Age e) Dte of Brth e) Dte of Admsson f) Tme g) Dte of Dschrge h) Tme ) Type of Admsson j) If Mternty Dte of Delvery Grvd Sttus k) Sttus t tme of dschrge l) Totl clmed mount ) ICD 10 Code Prmry Dgnoss Addtonl Dgnoss Co-morbdtes b) ICD 10 PCS Procedure 1 Procedure 2 Procedure 3 Detls of Procedure c) Present Alment s Complcton of PED d) Pre-uthorzton obtned e) Pre-uthorzton Number f) If uthorzton by network hosptl not obtned, gve reson g) Hosptlzton due to njury Cuse If njury due to substnce buse/lcohol Enter the nme of hosptl Enter ID number of hosptl Indcte whether In network or non network Hosptl Enter the nme of the tretng doctor Enter the qulfctons of the tretng doctor Enter the regstrton number of the doctor long wth the stte code Enter the phone number of doctor SECTION B - DETAILS OF THE PATIENT ADMITTED Enter the nme of hosptl Enter nsurnce provder regstrton number Indcte Gender of the ptent Enter ge of the ptent Enter dte of dmsson Enter tme of dmsson Enter dte of dschrge Enter tme of dschrge Indcte type of dmsson of ptent Enter Dte of Delvery f mternty Enter Grvd sttus f mternty Indcte sttus of ptent t tme of dschrge Indcte the totl clmed mount SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY) Enter the ICD 10 Code nd descrpton of the prmry dgnoss Enter the ICD 10 Code nd descrpton of the ddtonl dgnoss Enter the ICD 10 Code nd descrpton of the co-morbdtes Enter the ICD 10 PCS nd descrpton of the frst procedure Enter the ICD 10 PCS nd descrpton of the second procedure Enter the ICD 10 PCS nd descrpton of the thrd procedure Enter the detls of the procedure Indcte whether present lment s complcton of some pre- exstng dsese Indcte whether pre-uthorzton obtned Enter pre-uthorzton number Enter reson for not obtnng pre-uthorzton number Indcte f hosptlzton s due to njury Indcte cuse of njury Indcte whether test conducted consumpton, test conducted to estblsh ths Medco Legl Indcte whether njury s medco legl Reported To Polce Indcte whether polce report ws fled FIR No. Enter frst nformton report number If not reported to polce, gve reson Enter reson for not reportng to polce SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST Indcte whch supportng documents re submtted Nme of hosptl n full As llocted by the TPA Tck the rght opton Nme of doctor n full Abbrevtons of eductonl qulfctons As llocted by the Medcl Councl of Ind Include STD code wth telephone number Nme of hosptl n full As llotted by the nsurnce provder Tck Mle or Femle Number of yers nd months Use dd-mm-yy formt Use hh:mm formt Use dd-mm-yy formt Use hh:mm formt Tck the rght opton Use dd-mm-yy formt Use stndrd formt Tck the rght opton In rupees (do not enter pse vlues) Stndrd Formt nd Open text Stndrd Formt nd Open text Stndrd Formt nd Open text Stndrd Formt nd Open text Stndrd Formt nd Open text Stndrd Formt nd Open text Open text Tck Yes or No Tck Yes or No As llotted by TPA Open text Tck Yes or No Tck the rght opton Tck Yes or No Tck Yes or No Tck Yes or No As ssued by polce uthortes Open Text Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
8 DATA ELEMENT DESCRIPTION SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL ) Address Enter the full postl ddress b) Phone No. Enter the phone number of hosptl c) Regstrton No. wth Stte Code Enter the regstrton number of ptent d) Hosptl PAN Enter the permnent ccount number e) Number of Inptent Beds Enter the number of nptent beds f) Fcltes vlble n the hosptl Indcte fcltes vlble n the hosptl SECTION F - DECLARATION BY THE INSURED Red declrton crefully nd menton dte (n dd:mm:yy formt), plce (open text) nd sgn. SECTION G - DECLARATION BY THE HOSPITAL Red declrton crefully nd menton dte (n dd:mm:yy formt), plce (open text) nd sgn nd stmp. FORMAT Include Street, Cty nd Pn Code Include STD code wth telephone number As llocted by the Hosptl As llotted by the Income Tx deprtment Dgts Tck the rght opton. If others, plese specfy Insurnce s the subject mtter of solctton. For more detls on rsk fctors, terms nd condtons, plese red sles brochure crefully before concludng sle. IRDAI Regstrton Number: 155 CIN: U66000MH2016PLC GSTIN: 27AAFCD7985H1Z4 Regstered & Corporte Offce: 2nd Floor, DHFL House, 19, Shr Rod, Off Western Express Hghwy, Vle Prle (Est), Mumb
CLAIM FORM - PART A. TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability
CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The ssue of ths Form s not to be tken s n dmsson of lblty (To be flled n block letters) SECTION A - DETAILS OF PRIMARY INSURED Polcy No b Sl. No/Certfcte
More informationMediRaksha. Claim Form. Part A (To be filled in by the Insured)
MediRaksha Claim Form Tata AIG General Insurance Company Limited: A-501, 5th Floor, Building.4, Infinity Park, Gen. A.K. Vaidya Marg, Dindoshi, Malad (East), Mumbai 400 097 IMPORTANT: The Issue of this
More informationCLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A
SBI General Insurance Company Limited CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as
More informationSECTION A SECTION 8 SECTION C SECTION D SECTION E SECTION F SECTION G
CLAIM FORM - PART A TO 8E FILLED IN 8Y THE INSURED The issue of this Form is not to be taken as an admission of liability (To be filled in block letters) DETAILS OF PRIMARY INSURED: a) Policy No: b) Sl.
More information5 easy ways to speed up the claims process
Please return your completed claim form to: CignaTTK Health Insurance Company Limited OR Nearest Cigna TTK Branch. Corporate Office: 10th Floor, Commerz, International Business Park, Oberoi Garden City,
More informationCLAIM FORM. CLAIM FORM PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability
CLAIM FORM CLAIM FORM PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability SECTION A DETAILS OF PRIMARY INSURED a) Policy No b) Sl. No/ Certificate
More informationClaim form for health insurance policies other than travel and personal accident - PART A
M M Claim form for health insurance policies other than travel and personal accident - PART A TO BE FILLED IN BY THE INSURED (TO BE FILLED IN BLOCK LETTERS) The issue of this Form is not to be taken as
More information5 easy ways to speed up the claims process
Please return your completed claim form to: CignaTTK Health Insurance Company Limited OR Nearest Cigna TTK Branch. Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East),
More informationClaim Form
SECTION A - DETAILS OF PRIMARY INSURED (The issue of this Form is not to be taken as an admission of liability) PART A TO BE FILLED IN BY THE INSURED a) Policy No. : b) Sl. No/ Certificate No. : c) Company/
More informationClaim form for health insurance policies other than travel and personal accident - PART A
M M Claim form for health insurance policies other than travel and personal accident - PART A TO BE FILLED IN BY THE INSURED (TO BE FILLED IN BLOCK LETTERS) The issue of this Form is not to be taken as
More informationIn addition to above, if the claim amount is more than Rs 1 Lakh then following additional documents are required:
Health Insurance Ab Health Hamesha Broad Guidelines for Claim Process 1. Please ensure Claim form is completely filled, signed and submitted in original. 2. Please provide at least two contactable mobile
More informationCLAIM FORM (The issue of this Form is not to be taken as an admission of liability) PART A. Pin Code : Phone No. : d) Age (YY/MM) : Y Y M M
Claim Form Do You Know SECTIONA - DETAILS OF PRIMARY INSURED CLAIM FORM (The issue of this Form is not to be taken as an admission of liability) PART A TO BE FILLED IN BY THE INSURED a) Policy No. : b)
More informationClaim Form. Do You Know
Claim Form Do You Know SECTIONA - DETAILS OF PRIMARY INSURED CLAIM FORM (The issue of this Form is not to be taken as an admission of liability) PART A TO BE FILLED IN BY THE INSURED a) Policy No. : b)
More informationMembership Number: Suite. Deluxe Room. k) Type of hospitalization: Emergency / Planned. Rs. vi. External aids: viii.opd: ix.
CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED Claims Processing Centre: Shaw Wallace Building, New No. 319, Old No.154, 2nd Floor, Thambu Chetty Street, Parrys, Chennai- 600001 Toll Free Ph No.: 1800
More informationNational Insurance Company Limited
DETAILS OF THE THIRD PARTY ADMINISTRATOR a) Name of TPA / Insurance Company: b) Toll free phone number: c) Toll free Fax: CIN No. - U10200WB1906GOI001713 IRDA Regn. No. - 58 PLEASE FAX / SCAN PAGE 1 ONLY
More information(Surname) (First Name) (Middle Name) (DD/MM/YYYY) (Surname) (First Name) (Middle Name)
Health Insurance Ab Health Hamesha Claim Form - ASSURE Part A 1. To be filled in by the Insured. 2. The issue of this Form is not to be taken as an admission of liability. 3. To be filled in block letters.
More informationCLAIM FORM (The issue of this Form is not to be taken as an admission of liability) PART A. Pin Code : Phone No. :
Claim Form Do You Know SECTIONA - DETAILS OF PRIMARY INSURED CLAIM FORM (The issue of this Form is not to be taken as an admission of liability) PART A TO BE FILLED IN BY THE INSURED a) Policy No. : b)
More informationAb Health Hamesha. Health Insurance. Broad Guidelines for Claim Process. Brief description of the key documents required along with the claim form
Health Insurance Ab Health Hamesha Broad Guidelines for Claim Process 1. Please ensure Claim form is completely filled, signed and submitted in original. 2. Please provide at least two contactable mobile
More informationState: b) Date of commencement of first Insurance without break: State: d) Date of Injury / Date Disease first detected /Date of Delivery:
DETAILS OF PRIMARY INSURED a) PolicyNo Vipul Medcorp lnsurance TPA Pvt Ltd. Redefining Healthcare Services... CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO
More informationPARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD] Plot no.a-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate,
More informationCLAIM FORM FOR HEALTH INSURANCE POLICIES FOR INJURY/ILLNESS- (PART-A) TO BE FILLED IN BYTHE INSURED- STUDENT SAFETY ILLNESS & EMPLOYEE MEDICLAIM POLICY The issue of this Form is not to be taken as an admission
More informationPARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD] Plot no.a-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate,
More informationClaim Form - my:health Medisure Prime Insurance
Claim Form - my:health Medisure Prime Insurance GUIDELINES TO FILL THE FORM 1. Please fill the form in BLOCK LETTERS. Please answer all questions fully and correctly. All details with * are mandatory.
More information1. Detailed information about the Appellant s and Respondent s personal information including mobile no. and -id are to be furnished.
Revised Form 36 nd Form 36A for filing ppel nd cross objection respectively before income tx ppellte tribunl (Notifiction No. 72 dted 23.10.2018) Bckground CBDT issued drft notifiction vide press relese
More informationID: Yes. Yes. /No. months. b) Date of Birth: Spouse. Service Self Employed Homemaker Student Retired Other. ID:
INSURANCE TPA SERVICES (I) PVT.LT. 6B, Paul ansions, Bishop Lefroy Road, Kolkata 700 020, West Bengal, India ETAILS OF PRIAR INSURE (To be filled in block letters) a) Policy b) Company/ TPA I CLAI FOR
More informationCITY OF CHICAGO DEPARTMENT OF FINANCE APPLICATION FOR OFFER IN COMPROMISE OF A TAX DEBT BASED ON FINANCIAL HARDSHIP CITY OF CHICAGO
CITY OF CHICAGO DEPARTMENT OF FINANCE APPLICATION FOR OFFER IN COMPROMISE OF A TAX DEBT BASED ON FINANCIAL HARDSHIP CITY OF CHICAGO DEPARTMENT OF FINANCE (R-12/11) FINANCIAL HARDSHIP APPLICATION 1) Who
More informationa) Currently covered by any other Mediclaim / Health Insurance: Yes No b) If yes, Policy Type: Individual Group
CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED SECTION A - DETAILS OF PRIMARY INSURED: (To be filled in block letters) a) Policy
More informationCity of Covington EVENT PERMIT APPLICATION EVENTS ON CITY OWNED PROPERTY
Received By: PLEASE CHECK ONE OF THE FOLLOWING: Permit No.: This event is Specil Event defined s temporry community interest event, open to the generl public. For exmple; musement, recretionl, entertinment
More informationJune 30, 2017 (Q1-2018) March 31, 2017 (FY2017) (Audited) (Audited) (Audited) (Audited) (Audited) (Audited) 1. Interest earned (a)+(b)+(c)+(d)
Sr. ICICI Bnk Limited CIN-L65190GJ1994PLC021012 Registered Office: ICICI Bnk Tower, Ner Chkli Circle, Old Pdr Rod, Vdodr - 390 007. Corporte Office: ICICI Bnk Towers, Bndr-Kurl Complex, Bndr (Est), Mumbi
More informationSeptember 30, 2017 (Q2-2018) March 31, 2017 (FY2017) (Audited) (Audited) (Audited) (Audited) (Audited) (Audited) 1. Interest earned (a)+(b)+(c)+(d)
2 ICICI Bnk Limited CIN-L65190GJ1994PLC021012 Registered Office: ICICI Bnk Tower, Ner Chkli Circle, Old Pdr Rod, Vdodr - 390 007. Corporte Office: ICICI Bnk Towers, Bndr-Kurl Complex, Bndr (Est), Mumbi
More information)''/?\Xck_
bcbsnc.com Deductible options: $250, $500, $1,000 or $2,500 Deductible options $500, $1,000, $2,500, $3,500 or $5,000 D or (100% coinsurnce is not vilble on the $2,500 deductible option) coinsurnce plns:
More informationFirst Assignment, Federal Income Tax, Spring 2019 O Reilly. For Monday, January 14th, please complete problem set one (attached).
First Assignment, Federl Income Tx, Spring 2019 O Reilly For Mondy, Jnury 14th, plese complete problem set one (ttched). Federl Income Tx Spring 2019 Problem Set One Suppose tht in 2018, Greene is 32,
More informationWHEREAS, on September I, 2009, the parties made and entered into City of Jacksonville Contract No (the "Agreement"); and
SECOND MENDMENT TO GREEMENT BETWEEN CTY OF JCKSONVLLE ND ULD & WHTE CONSTRUCTORS, NC. FOR DESGN BULD SERVCES FOR MNOR- MEDUM SZE CVL ENGNEERNG & PRK MPROVEMENT PROJECTS (SOUTH RE) ~H~ SECOND MENDMENT to
More informationMarch 31, 2016 (FY2016) (Audited) (Audited) (Audited) (Audited) (Audited) 1. Interest earned (a)+(b)+(c)+(d)
2 Sr. no. ICICI Bnk Limited CIN-L65190GJ1994PLC021012 Registered Office: ICICI Bnk Tower, Ner Chkli Circle, Old Pdr Rod, Vdodr - 390 007. Corporte Office: ICICI Bnk Towers, Bndr-Kurl Complex, Bndr (Est),
More information180 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II SEC. 3()] FORM ITR-1 SAHAJ INDIAN INCOME TAX RETURN [For ndvduls beng resdent other thn not ordnrly
¹Hkkx IIµ[k.M 3()º Hkkjr dk jkt=k % vlk/kj.k 179 MINISTRY OF FINANCE (Deprtment of Revenue) (CENTRAL BOARD OF DIRECT TAXES]) NOTIFICATION New Delh, the 3rd Aprl, 2018 Income-tx G.S.R. 332(E). In exercse
More informationTrivial lump sum R5.0
Optons form Once you have flled n ths form, please return t wth your orgnal brth certfcate to: Premer PO Box 108 BLYTH NE24 9DY Fll n ths form usng BLOCK CAPITALS and black nk. Mark all answers wth an
More informationPreauthorization Form Request For Cashless Hospitalisation For Medical Insurance Policy
Aditya Birla Health Insurance Co. Limited Preauthorization Form Request For Cashless Hospitalisation For Medical Insurance Policy DETAILS OF THE THIRD PARTY ADMINISTRATOR (To be filled in block letters)
More information~~~~ACT Sally hayes. Io"bA~~ss: INSURER D:
CORD CERTFCTE OF PROPERTY NSURNCE DTE (MMDDYYYY) ~ 5/29/2015 THS CERTFCTE S SSUED S MTTER OF NFORMTON ONLY ND CONFERS NO RGHTS UPON THE CERTFCTE HOLDER. THS CERTFCTE DOES NOT FFRMTVELY OR NEGTVELY MEND,
More information(Audited) (Audited) (Audited) (Audited) 1. Interest earned (a)+(b)+(c)+(d)
2 ICICI Bnk Limited CIN-L65190GJ1994PLC021012 Registered Office: ICICI Bnk Tower, Ner Chkli Circle, Old Pdr Rod, Vdodr - 390 007. Corporte Office: ICICI Bnk Towers, Bndr-Kurl Complex, Bndr (Est), Mumbi
More informationSr. Particulars no. (Audited) (Audited) (Audited) (Audited) (Audited) (Audited) 1. Interest earned (a)+(b)+(c)+(d)
2 ICICI Bnk Limited CIN-L65190GJ1994PLC021012 Registered Office: ICICI Bnk Tower, Ner Chkli Circle, Old Pdr Rod, Vdodr - 390 007. Corporte Office: ICICI Bnk Towers, Bndr-Kurl Complex, Bndr (Est), Mumbi
More informationBusiness Fees and Charges
Business Fees nd Chrges 21 August 2017 1 COVER IMAGE: Drren Rpid Auto Locl Business Member Goulburn Fee Summry Tble Everydy Trnsction Account Everydy Business (S90) Monthly Service Fee Trnsction Fees rediatm
More informationTrivial lump sum R5.1
Trval lump sum R5.1 Optons form Once you have flled n ths form, please return t wth the documents we have requested. You can ether post or emal the form and the documents to us. Premer PO Box 108 BLYTH
More informationMembers not eligible for this option
DC - Lump sum optons R6.1 Uncrystallsed funds penson lump sum An uncrystallsed funds penson lump sum, known as a UFPLS (also called a FLUMP), s a way of takng your penson pot wthout takng money from a
More informationchecks are tax current income.
Humn Short Term Disbility Pln Wht is Disbility Insurnce? An esy explntion is; Disbility Insurnce is protection for your pycheck. Imgine if you were suddenly disbled, unble to work, due to n ccident or
More informationMembers not eligible for this option
DC - Lump sum optons R6.2 Uncrystallsed funds penson lump sum An uncrystallsed funds penson lump sum, known as a UFPLS (also called a FLUMP), s a way of takng your penson pot wthout takng money from a
More informationHDFC LIFE - CANCER CARE CLAIM FORM
PSNF542702031602 Comp/feb/Int/4632 Page 1/7 HDFC LIFE - CANCER CARE CLAIM FORM PART A This form is to be filled by the claimant in block letters. The issue of this form is not to be taken as an admission
More informationPSAS: Government transfers what you need to know
PSAS: Government trnsfers wht you need to know Ferury 2018 Overview This summry will provide users with n understnding of the significnt recognition, presenttion nd disclosure requirements of the stndrd.
More informationPARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
PARAOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIITE (IRA License. 006) [formerly known as PARAOUNT HEALTH SERVICES (TPA) PVT.LT] Plot no.a-442, Road -28,.I..C Industrial Area, Wagale Estate, Ram Nagar,
More informationAPPENDIX 5 FORMS RELATING TO LISTING FORM F GEM COMPANY INFORMATION SHEET
APPENDIX 5 FORMS RELATING TO LISTING FORM F GEM COMPANY INFORMATION SHEET Cse Number: 20180815-I18008-0004 Hong Kong Exchnges nd Clering Limited nd The Stock Exchnge of Hong Kong Limited tke no responsibility
More informationCOFUNDS PENSION ACCOUNT TRANSFER REQUEST FORM for existing clients
COFUNDS PENSION ACCOUNT TRANSFER REQUEST FORM for exstng clents Also avalable on the Aegon webste: Cofunds Penson Account Drawdown Transfer Request Form transfer a penson plan from whch full or partal
More informationTable of Benefits CORPORATE GROUP SCHEMES. Corporate Healthcare Plan for the Channel Islands Valid from 1st November 2017
Corporte Helthcre Pln for the Chnnel Islnds Vlid from 1st November 2017 CORPORATE GROUP SCHEMES Tble of Benefits Avilble for corporte groups of three employees or more. REASONS TO CHOOSE US Single point
More information(A1) First Name (A2) Middle Name (A3) Last Name (A4) Permanent Account Number
FORM ITR-4 SUGAM INDIAN INCOME TAX RETURN [For Indvduals, HUFs and Frms (other than LLP) beng a resdent havng total ncome upto Rs.50 lakh and havng ncome from busness and professon whch s computed under
More informationFlat/Door/Block No Name Of Premises/Building/Village Date of formation/incorporation (DD/MM/YYYY) / /
FORM ITR-7 INDIAN INCOME TAX RETURN [For persons ncludng compnes requred to furnsh return under sectons 139(4A) or 139(4B) or 139(4C) or 139(4D) or 139(4E) or 139(4F)] (Plese see rule 1 of the Income-tx
More informationAppendix U: THE BOARD OF MANAGEMENT FOR THE REGAL HEIGHTS VILLAGE BUSINESS IMPROVEMENT AREA. Financial Statements For the Year Ended December 31, 2011
I Appendix U: Finncil Sttements For the Yer Ended December 31, 2011 0 DECEMBER 31, 2011 CONTENTS Pce Independent uditor s report 3 Finncil sttements Sttement of finncil position 4 Sttement of opertions
More informationICICI Lombard Health Care Claim Form - Hospitalisation (Issuance of this form is not to be taken as an admission of liability)
ICICI Lombard Health Care Claim Form - Hospitalisation (Issuance of this form is not to be taken as an admission of liability) Overview Health Claim Form - Hospitalization ICICI Lombard Health Care Part
More informationP.O. Box 267, 14-18, Castle Street, St. Helier, Jersey JE4 8TP
Securities Divion INITIAL REVIEW CHECKLIST FOR FUNDS P.O. Box 67, 14-18, Cstle Street, St. Helier, Jersey JE4 8TP Tel: (44) 1534 8000 Fx: (44) 1534 8047 April 008 Declrtion I/We declre tht informtion given
More informationCardholder Application Form
Cardholder Applcaton Form Place a cross aganst the product for whch you requre a new cardholder. onecard Corporate Card Purchasng Card Gudelnes for completng ths form On screen Use the tab key to move
More information1S CLAIMANT STATEMENT FORM (HEALTH CLAIMS)
24x7 CustomerHelpline No: 1860 266 7766 CLAIM FORM - PART A TO BE FILLE IN BY THE INSURE The issue of this Form is not to be taken as an admission of liability 1S CLAIMANT STATEMENT FORM (HEALTH CLAIMS)
More informationIn the Income-tax rules, 1962 (hereinafter referred to as the principal rules), in rule 12,(a) in sub-rule (1),(I)
I N COM E TAX -COPY OFN OTI FI CATI ON N O. 6 / 0 8 D t e d r d Apr l, 0 8 In exercse of the powers conferred y secton 9 red wth secton 95 of the Income-tx Act, 96 ( of 96), the Centrl Bord of Drect Txes
More informationExhibit A Covered Employee Notification of Rights Materials Regarding Allied Managed Care Incorporated Allied Managed Care MPN MPN ID # 2360
Covered Notifiction of Rights Mterils Regrding Allied Mnged Cre Incorported Allied Mnged Cre MPN This pmphlet contins importnt informtion bout your medicl cre in cse of workrelted injmy or illness You
More informationFinancial Statement Auditor s Report
Coo r r"', nstructons Mnstry of Muncpal Affars Ontaro and Housng All canddates must complete Boxes A, B, C, D, E and F and Schedule Fnancal Statement Audtor s Report Form 4 Muncpal Electons Act, 1996(
More informationICICI Lombard Health Care Claim Form - Hospitalisation (Issuance of this form is not to be taken as an admission of liability)
ICICI Lombard Health Care Claim Form - Hospitalisation (Issuance of this form is not to be taken as an admission of liability) ICICI Lombard Health Care Do You Know «Non-submission of original bills and
More informationFirst name Middle name Last name
FORM ITR-2 Assessment Year INDIAN INCOME TAX RETURN [For Indvduals and HUFs not havng Income from Busness or Professon] (Please see Rule 12 of the Income-tax Rules,1962) (Also see attached nstructons)
More informationFirst name Middle name Last name PAN. Flat/Door/Block No Name Of Premises/Building/Village Status (Tick)
FORM ITR-2 INDIAN INCOME TAX RETURN [For Indvduals and HUFs not havng Income from Busness or Professon] (Please see Rule 12 of the Income-tax Rules,1962) (Also see attached nstructons) Assessment Year
More informationFirst name Middle name Last name
FORM ITR-2 Assessment Year INDIAN INCOME TAX RETURN [For Indvduals and HUFs not havng Income from Busness or Professon] (Please see Rule 12 of the Income-tax Rules,1962) (Also see attached nstructons)
More informationLIST OF DOCUMENTS REQUIRED FOR SETTLEMENT OF HOSPITALISATION CLAIMS
LIST OF OCUENTS REQUIRE FOR SETTLEENT OF HOSPITALISATION CLAIS 1. FOR CLAIING HOSPITALISATION EXPENSES A CLAI FOR PART A: UL COPLETE B THE INSURE ON THE PRESCRIBE FORAT - ORIGINAL B CLAI FOR PART B: UL
More informationffip tiht&ry] Copy to portal. (Odisha Livelihoods Mission) Kacheri Road, Pin:752001, Ph No:A
DSTRCT RURAL DEVELOPMENT AGENCY - PUR (Odish Livelihoods Mission) Kcheri Rod, Pin:752001, Ph No:A6752-225441 No. V, u Dte: 19 'o l'17 QUOTATON CALL NOTCE Seled quottions re invited in the prescribed formt
More informationPart A-GEN GENERAL First name Middle name Last name
FORM ITR-3 INDIAN INCOME TAX RETURN [For Indvduals/HUFs beng partners n frms and not carryng out busness or professon under any propretorshp] (Please see rule 12 of the Income-tax Rules,1962) (Also see
More informationScholarship Application
Scholrship Appliction Prt 1. Plyers enrolled in NB Ajx Soccer Club seeking scholrship. Nmes (First, Middle Initil, Lst) & Tem (Exmple: 96 Girls White or SNAP(formerly food stmp U17) progrm), TANF, CHIPS/Medicid
More informationThe Morgan Stanley FTSE Growth Optimiser Plan
The Morgn Stnley FTSE Growth Optimiser Pln Offering choice of two FTSE 100 linked growth plns Choose the growth nd risk profile tht meets your investment needs The Morgn Stnley FTSE 100 Growth Optimiser
More information(a) by substituting u = x + 10 and applying the result on page 869 on the text, (b) integrating by parts with u = ln(x + 10), dv = dx, v = x, and
Supplementry Questions for HP Chpter 5. Derive the formul ln( + 0) d = ( + 0) ln( + 0) + C in three wys: () by substituting u = + 0 nd pplying the result on pge 869 on the tet, (b) integrting by prts with
More informationINDIAN RAILWAY FINANCE CORPORATION LTD.
INDIAN RAILWAY FINANCE CORPORATION LTD. f Tx-Free Secured Redeemble Non-Convertible Bonds ISSUE HIGHLIGHTS Issue opens: Tuesdy, December 8, 2015 Issue closes: Mondy, December 21, 2015 Allotment: Fce Vlue:
More informationPART-B. a from sources other than from owning race horses and Winnings from Lottery
FORM ITR-2 Assessment Year INDIAN INCOME TAX RETURN [For Indvduals and HUFs not havng Income from Busness or Professon] (Please see Rule 12 of the Income-tax Rules,1962) (Also see attached nstructons)
More informationPart A-GEN GENERAL First name Middle name Last name PAN
FORM ITR-3 INDIAN INCOME TAX RETURN [For Indvduals/HUFs beng partners n frms and not carryng out busness or professon under any propretorshp] (Please see rule 12 of the Income-tax Rules,1962) (Also see
More informationCOMPLETE COVER - `ADD ON' TO TRAVEL INSURANCE POLICIES CONFERENCE & EVENT ORGANISERS SCHEDULE
SPECIMEN ONLY COMPLETE COVER - `ADD ON' TO TRAVEL INSURANCE POLICIES CONFERENCE & EVENT ORGANISERS SCHEDULE Policy Numer: Policyholder: Certificte of Insurnce: PPIP(E) Period of Insurnce: Finncil Loss:
More informationCode No: 707 Advice No: Advice Date: 31/03/2018
nips: ptms.nic. n nctioiifcmpltcadvice.spx?adviccnum2l'!h. PAO(Sectt.)/H&UA/Admin/Advice/2171/ GOVERNMENT OF INDIA PAO(Sectt.), Ministryof Urbn Development 57C Wing, Nirmn Bhwn, New Delhi Telephone No:
More informationStudent Retired Student Others. Mobile Home Work. Student Retired Student Others. Self-inflicted road traffic accident substance abuse alcohol abuse
HEALTH INSURANCE Aditya Birla Health Insurance Co. Limited Claim Form Part A - Personal Accident SECTION A 1. Details of the Proposer: a) Policy No.: b) Name of the Insured: c) Date of Birth: d) Marital
More informationChina Construction Bank Corporation (the Company ) Date Submitted 28 September (1) Stock code : Description : H Shares
Monthly Return of Equity Issuer on Movements in Securities For the ended : 30/09/2018 To : Hong Kong Exchnges nd Clering Limited Nme of Issuer Chin Construction Bnk Corportion (the Compny ) Dte Submitted
More informationReceipt. EOI Direct. Receipt $57.95 $0.00. Total Due. Customer Account User Payment Terms Due Date American Pacific Mortgage Due on Receipt
EOI Direct 1880 W. Judith Lane, Suite 220 Boise, ID 83705 Voice: (877) 456-3643 Fax: (208) 694-3848 Receipt Order Number: 1716217 Date: 03/28/2017 Sold To: merican Pacific Mortgage 1741 E. Roseville Parkway,
More information(Also see attached instructions) Pin code
FORM ITR-4 INDIAN INCOME TAX RETURN ( For ndvduls nd HUFs hvng ncome from propretory busness or professon) (Plese see rule 12 of the Income-tx Rules,1962) Assessment Yer (Also see ttched nstructons) 2
More informationTo: All Affiliates/Office Bearers/Central Committee Members Dear Sir/Madam,
ALL INIA CANARA BANK RETIREES FEERATION (Regd.) (Affiliated to All India Bank Retirees Federation) A.K.Nayak Bhavan, 2 nd Floor, 14, Second Line Beach, Chennai 600001. Ref No:97:2015 November 11, 2015
More informationVISAGAR FI_NANCIAL SERVICES. LIMITED
2 Expenses ) ost of Mterils onsumed ) Purchse of stock intrde hnges in inventories of finished goods, workinprogress nd c) stockintrde. e) f) g) 3 4 Exceptionl items 5 Profit/ (Loss) from ordinry ctivities
More informationADDENDUM - I Dated
ADDENDUM - Dated 27.07.2015 Page : 1 {To be submtted alongwth Techncal Bd, Part - (Envelope - 1)} Tender For Supply, Fabrcaton, Erecton & Commssonng of Sewage Treatment Plant at Baroda Corporate Centre,
More informationHRDD CIRCULAR NO. 723
Human Resources Development Division (Hospitalisation Cell), Head Office: New Delhi Phone No. 011-26174730 Email hrdhospitalisation@pnb.co.in FAX 011-26196491 November 19, 2015 TO ALL OFFICES HRDD CIRCULAR
More information(1) Stock code : Description : H Shares. No. of ordinary shares. (2) Stock code : Description : A Shares. No. of ordinary shares
Monthly Return of Equity Issuer on Movements in Securities For the ended : 31/10/2017 To : Hong Kong Exchnges nd Clering Limited Nme of Issuer Dte Submitted 1 November 2017 Chin Construction Bnk Corportion
More informationFROM CODE AMOUNT CODE AMOUNT CODE AMOUNT. b c d 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 CREATION DATE 52 REL.
1 2 3 PT. 4 TYPE NTL # OF ILL.MED. RE. # 5 FED.TX NO. 6 STTEMENT OVERS PERIOD 7 FROM THROUGH 8 PTIENT NME 9 PTIENT DDRESS c d 10 IRTHDTE 11 SEX DMISSION ONDITION ODES 12 DTE 13 HR 14 TYPE 15 SR 16 DHR
More informationFAQ (FREQUENTLY ASKED QUESTIONS) ON MEDICAL INSURANCE SCHEME FOR RETIRED EMPLOYEES OF PUNJAB & SIND BANK
FAQ (FREQUENTLY ASKED QUESTIONS) ON MEDICAL INSURANCE SCHEME FOR RETIRED EMPLOYEES OF PUNJAB & SIND BANK 1. What is the definition of family under the scheme? The family of a retired employee includes
More informationAPPLICATION / CANCELLATION / TRANSFER / POLICY CHANGE SECTION
g PPLCNT S/NSUREDS NME: GENCY: STREET ND/OR MLNG DDRESS: DDRESS: CTY: STTE: PPLCNT S/NSURED S TELEPHONE NUMBER: DENTFCTON NUMBER: DENTFCTON NUMBER TYPE: GENCY CODE: EFFECTVE POLCY YER: POLCY NUMBER: STTE/COUNTY:
More information5th Floor, Lodha Excelus, Apollo Mills Compound N. M. Joshi Marg, Mahalaxmi. India
Chrtered Accountnts 5th Floor, Lodh Excelus, Apollo Mills Compound N. M. Joshi Mrg, Mhlxmi Mumbi - 400 011 Indi Telephone +91 (22) 4345 5300 +91 (22) 4345 5399 Fx Limited Review Report on Unudited Consolidted
More informationHDFC ERGO General Insurance Company Limited
HFC ERGO General Insurance Company Limited CLAI FOR FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT CLAI FOR PART A To be filled in by e Insured The issue of is form is not to be taken
More informationINDIAN INCOME TAX RETURN ( Including Fringe Benefit Tax Return) [For firms, AOPs and BOIs] (Please see Rule 12 of the Income-tax Rules,1962)
FORM ITR-5 INDIAN INCOME TAX RETURN ( Includng Frnge Beneft Tx Return) [For frms, AOPs nd BOIs] (Plese see Rule 12 of the Income-tx Rules,1962) Assessment Yer (Also see ttched nstructons) 2 0 0 7-0 8 Prt
More informationFirst name Middle name Last name
FORM ITR-3 INDIAN INCOME TAX RETURN [For Indvduals/HUFs beng partners n frms and not carryng out busness or professon under any propretorshp] (Please see rule of the Income-tax Rules,96) (Also see attached
More informationICICI Lombard Health Care Claim Form - Hospitalisation (Issuance of this form is not to be taken as an admission of liability)
ICICI Lombard Health Care Claim Form - Hospitalisation (Issuance of this form is not to be taken as an admission of liability) Overview Health Claim Form - Hospitalization Documents Submitted ICICI Lombard
More informationInternational Budget Partnership OPEN BUDGET QUESTIONNAIRE Sri Lanka, September 2009
Interntionl Budget Prtnership OPEN BUDGET QUESTIONNAIRE Sri Lnk, September 2009 Interntionl Budget Prtnership Center on Budget nd Policy Priorities 820 First Street NE, Suite 510 Wshington, DC 20002 www.interntionlbudget.org
More informationFlat/Door/Block No Name Of Premises/Building/Village Date of formation/incorporation (DD/MM/YYYY)
FORM ITR-7 INDIAN INCOME TAX RETURN [For persons ncludng compnes requred to furnsh return under sectons 9(4A) or 9(4B) or 9(4C) or 9(4D) only] (Plese see rule of the Income-tx Rules, 96) (Plese refer nstructons
More informationPillar 3 Quantitative Disclosure
Pillr 3 Quntittive Disclosure In complince with the requirements under Bsel Pillr 3 nd the Monetry Authority of Singpore (MAS) Notice 637 Public Disclosure, vrious dditionl quntittive nd qulittive disclosures
More informationPillar 3 Quantitative Disclosure
Pillr 3 Quntittive Disclosure In complince with the requirements under Bsel Pillr 3 nd the Monetry Authority of Singpore (MAS) Notice 637 Public Disclosure, vrious dditionl quntittive nd qulittive disclosures
More informationa v p a v p a (60, 000) (1.05) ( )(2.743) (1.05) ( )(9.6612) 15, 065 Pa P a v p a v p a
1. Dimos Disbility Insurnce Compny uses the Stnr Sickness-Deth Moel with i 0.05 to price n reserve its isbility income policies. Dimos sells 10 yer isbility income policy. The policy pys premiums continuously
More informationFINANCIAL ANALYSIS I. INTRODUCTION AND METHODOLOGY
Dhk Wter Supply Network Improvement Project (RRP BAN 47254003) FINANCIAL ANALYSIS I. INTRODUCTION AND METHODOLOGY A. Introduction 1. The Asin Development Bnk (ADB) finncil nlysis of the proposed Dhk Wter
More informationFILED: NEW YORK COUNTY CLERK 10/21/ :13 PM INDEX NO /2015 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/21/2016. Exhibit A
FILED: NEW YORK COUNTY CLERK 10/21/2016 03:13 PM INDE NO. 159662/2015 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/21/2016 Exhibit COMMERCIL GENERL LIBILITY CLIMS-MDE GEN'L GGREGTE LIMIT PPLIES PER: PRO- POLICY
More information