MEDSAVE HEALTHCARE (TPA) LIMITED F- 701, Lado Sarai, Mehrauli New Delhi Web: CHECKLIST OF ENCLOSURES FOR SUBMISSION OF CLAIM
|
|
- Maurice McGee
- 5 years ago
- Views:
Transcription
1 Toll Free No: ESAVE HEALTHCARE (TPA) LIITE F- 701, Lado Sarai, ehrauli New elhi Web: CHECKLIST OF ENCLOSURES FOR SUBISSION OF CLAI [Please tick the appropriate [ ] box] Name of the claimant:. Employee Code: CAR No:.. Policy No: No of Enclosures:.. ate Of Submission:... GENERAL 1. uly filled & Signed claim form by insured [ ] 2. Photo copy of E Card/ health Card [ ] 3. Photo copy of I Card * [ ] 4. Original copy of consolidated bill of hospital with breakup [ ] 5. Original copy of receipt of payment [ ] 6. All original prescription for bill attached [ ] 7. All original investigation /pathological/reports along with films/c. [ ] 8. Original discharge summary of hospital duly Signed by the treating doctor with hospital Seal and registration number. [ ] 9. Original invoice of implants (viz Stents/ PHS mesh /IOL etc) [ ] 10. First consultation letter for the presenting Complaints. [ ] 11. Pre/Post hospitalization bills/receipts/ reports in original pertaining to the incidence for which hospitalization has happened [ ] 12. Original prescription/doctors notes of previous treatment for the presenting complaints [ ] 13. Cancelled cheque along with IFSC details or a copy of the pass book and NEFT form [ ] FOR EATH CASES 1. Attested copy of death summary of the hospital duly signed by the treating doctor with hospital seal and registration number [ ] 2. Attested copy of death certificate from competent authorities [ ] 3. Legal Heir certificate/ letter from the underwriting office to settle the claim in the name of nominee/ dependents [ ] FOR ATERNIT CASE 1. Original copy of treating doctor s certificate regarding obstetric history (Gravida, Para, Living Children, Abortions, eath) [ ] FOR RTA 1. Attested copy of LC Report [ ] 2. Attested Copy of FIR [ ] 3. Original copy of treating doctor s certificate with circumstances and injuries sustained due to RTA [ ] 4. Original copy of Treating doctors certificate for any evidence of influence of Alcohol/ other Narcotics substance during the accident [ ] Checklist of Enclosures for submission of claim
2 Toll Free No: *Photo Copy of I Card: Any Govt. Issued I card (PAN card, Passport Copy, AAHAR card, Voter Id proof etc) In case of new born babies the identity proof of the mother and the hospital authorization letter/ischarge Card/unicipal Birth Certificate (if available) In case of children- School Identity Card along with Guardian s I proof Under Taking: I / We hereby confirm that the above mentioned documents in support of the claimed amount have been submitted in full and final. No other documents would be submitted on a later date, that will alter and enhance the claim value. ate : Signature Place:. Name:. Address: City:.. Pin:.. obile No:. E mail: isclaimer: We acknowledge receipt of your claim and confirm that it has been registered with us on the basis of above documents. However the above acknowledgement does not guarantee settlement/ payment of claimed amount. This claim will be subject to pass through medical and commercial scrutiny, which may call for additional document that needs to be submitted within the stipulated time frame on intimation. ate: Name of Claimant Signature For edsave Place: Checklist of Enclosures for submission of claim
3 ediassist a) Policy No.: c) Company/ TPA I (A I) No: R REIBURSEENT CLAI FOR TO BE FILLE B THE INSURE The issue of this Form is not to be taken as an admission of liability ETAIS OF PRIAR INSURE: b) Sl.No/ Certificate no. (To be Filled in block letters) )Name: S U R N A E F I R S T N A E I L E N A E e) Address: City: Pin Code Phone No: I: a) Currently covered by any other ediclaim /Health Insurance: es No c) If yes, company name: Policy No. b) Claim for omiciliary Hospitalization: es No State: ETAILS OF INSURANCE HISTOR: b) ate of commencement of first Insurance without break: Sum insured () d) Have you been hospitalized in the last four years since inception of the contract? es No ate: iagnosis: e) Previously covered by any other ediclaim / Health insurance:: es No f)if yes \,company name: ETAILS OF INSURE PERSON HOSPITALIZE: a) Name: S U R N A E F I R S T N A E I L E N A E b) Gender ale Female c)age years onths d) ate of Birth e) Relationship to Primary insured: Self Spouse Child Father other Other (Please Specify) f) Occupation Service Self Employed Home aker Student Retired Other (Please Specify) g) Address (if different from above): City: Pin Code Phone No: I : a) Name of Hospital where Admited: ETAILS OF HOSPITALIZATION: b) Room Category occupied: aycare Single occupancy Twin sharing 3ormorebedsperroom c) Hospitalization due to: Injury Illness aternity d)ate of injury /ate isease first detected /ate of elivery: d) ate of Admission: f) Time H H H g) ate of ischarge: h) Time: H H : H I) If injury give cause :Self inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption I) If edico legal es No ii) Reported to Police iiii. L C Report &Police FIR attached es No j)system of edicine: a) etails of the Treatment expenses claimed I. Pre-hospitalization expenses iii. Post-hospitalization expenses iv. Ambulance Charges: ETAILS OF CLAI: ii. Hospitalization expenses v. Health Check up cost: vi. Others(code): Total State: Claim ocuments Submitted-Check List: Claim form duly signed Copy of the claim intimation, if any Hospital ain Bill Hospital Break-up Bill Hospital Bill Payment Receipt vii. Pre-hospitalization period: days viii.post-hospitalization period: days Hospital ischarge Summary c) etails of Lump sum/ cash benefit claimed: i. Hospital aily cash: (If yes, provide details in annexure) ii. Surgical Cash: Pharmacy Bill OperationTheater Notes iii. Critical Illness benefit: iv. Convalescence: octor s request for investigation Investigation Reports (Including CT v. Pre /Post hospitalization Lump sum benefit:: vi. Others: Total /RI/USG/HPE) octor s Prescriptions Others Sl.No a) PAN: BillNo. c) Bank Name and Branch: ate Issuedby ETAILS OF BILLS ENCLOSE: Towards ETAILS OF PRIAR INSURE S BANK ACCOUNT: b)account Number: Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills Nos Nos ECG Amount (Rs) SECTIONA SECTIONB SECTIONC SECTION SECTIONE SECTIONF SECTIONG d) Cheque/ Payable details: e) IFSC Code: ANTI-ONE LAUNERING REQUIREENT (For claim more than or equal to 1 Lakh - One ocument each from (1) and (2)) 1. Proposer s Identification (a) Passport (b) PAN Card (c) Voter s I Card (d) riving License (e) AAHAR Card 2. Proposer s Address (a) Current Telephone /obile Bill (b) Current Bank Passbook (c) Electricity Bill (d) Ration Card (e) Valid Rent Lease Agreement (IPORTANT: PLEASE TURNOVER)
4 ECLARATION BTHE INSURE: I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA / insurance Company, to seek necessary medical information / documents from any hospital / edical 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 I will not be making any supplementary claim except the pre/post-hospitalization claim, if any. SECTIONH. ate Place: Signature of the Insured GUIANCEFOR FILLING CLAI FOR - PARTA(To be filled in by the insured) ATA ELEENT ESCRIPTION FORAT SECTION A- ETAILS OF PRIARINSURE a) Policy No. Enter the policy number As allotted by the Insurance Company b) Sl. No/ Certificate No. Entert he social Insurance number or the certificate number of social health insurance scheme As allotted y the oraganization c) Company TPAI No. Enter the TPAI No. Licence number as allotted by IRA and printed in TPA documents. d) Name Enter the full name of the policyholder Surname, First name, iddle name e) Address Enter the full postal address Include Street, City and Pin code a) Currently covered by any other ediclaim / Health Insurance? SECTION B -ETAILS OF INSURANCEHISTOR Indicate whether currently covered by another ediclaim /Health Insurance Tick es or No b) ate of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat c) Company Name Enter the full name of the Insurance Company Name of the organization in full Policy No. Enter the policy number As allotted by the Insurance Company Sum insured Enter the total sum insured as per the policy In rupees d) Have you been Hospitalized in the last four years since Inception of the contract? Indicate whether hospitalized in the last four years Tick es or No ate Enter the date of Hospitalization Use mm-yy format iagnosis Enter the diagnosis details Open Text e) Previously covered by any other ediclaim / Health Insurance? Indicate whether previously covered by another mediclaim / Health Insurance Tick es or No f) Company Name Enter the full name of the Insurance Company Name of the organization in full SECTION C -ETAILS OF INSUREPERSON HOSPITALIZE a) Name Enter the full name of the patient Surname, First name, iddle name b) Gender Indicate Gender of the patient Tick ale or Female c) Age Enter age of the patient Number of years and months d) ate of Birth Enter ate of Birth of patient Use dd-mm-yy format e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option if others,please specify f) Occupation indicate occupation of patient Tick the right option. If others please specify. g) Address Enter the full postal address Include Street, City and Pin code h) Phone No Enter the phone number of patient Include ST code with 1) I Enter address of patient Complete address SECTION - ETAILS OF HOSPITALIZATION a) Name of Hospital where admited Enter the name of hospital Name of hospital in full b) Room category occupied indicate the room category occupied Tick the right option c) Hospitalization due to indicate reason of hospitalization Tick the right option d) ate of injury/ ate isease first detected / ate of elivery Enter the relevant date Use dd-mm-yy format e) ate of admission Enter date of admission Use dd-mm-yy format f) Time Enter time of admission Use hh-mm- format g) ate of discharge Enter date of discharge Use dd-mm-yy format h) Time Enter time of discharge Use hh-mm- format I) If injury give cause indicate cause of injury Tick the right option If edico legal indicate whether injuryis medico legal Tick es or No Reported to Police indicate whether police report was filed Tick es or No LC Report& Police FIR attached indicate whether LC report and Police FIR attached Tick es or No j) System of edicene Enter the system of medicine followed in treating the patient Open Text SECTION E - ETAILS OF CLAI a) etails of Treatment Expences Enter the amount claimed as treatment expences In rupees (o not enter paise values) b) Claim for omiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick es or No c) etails of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit In rupees (o not enter paise values) d) Claim documents Submitted-Check List indicate which supporting documents are submitted Tick the right option Indicate which bills are enclosed with the amount in rupees SECTION F - ETAILS OF BILLS ENCLOSE SECTION G - ETAILS OF PRIAR IN SURE s BANKACCOUNT a) PAN Enter the permanent account number As allotted by the Income Tax epartment b) Account Number Enter the Bank account number As allotted by the Bank c) Bank Name and Branch Entert he Bank name along with the branch Name of the Bank in full c) Cheque/ payable details Enter the name of the beneficiary the cheque / should be made out to Name of the individual / organization in full c) IFSC Code Enter the IFSC code of the Bank branch IFSC code of the Bank branch in full Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. SECTION H - ECLARATIONBTHE INSURE
5 NEFT Format To edsave Healthcare (TPA) Limited F-701A, Lado Sarai, ehrauli, New elhi Sirs, I / We furnish below details of my /our bank account to be used for effecting payments due to us by NEFT / RTGS: Registration for NEFT / RTGS Payments Name Category (Please select one) Policyholder / Intermediary / Surveyor / Advocate / Investigator / Panel octor / ealer / Landlord / Vendor Policy Number (Policyholders only) Claim number, if any, provided (Policyholders only) Agency / Broker Code (for Agents / Brokers / Corporate Agents / Bancassurance only) Permanent Address Address for Communication BANK ACCOUNT ETAILS FOR NEFT / RTGS PAENTS IFSC Code * Bank Name Bank Branch Name Bank Branch Address ICR Code (9 igit number) Full Bank Account No. (for NEFT) * * Please attach a copy of a cancelled cheque leaf. Verify the details with your bank before submitting. I wish to receive alerts from the Company on processing of payments to my account through SS and / or obile Phone No. (for SS alert) I (for mail notification) (please write in BLOCK letters) I/We hereby declare that the particulars given above are correct and express my/our willingness to receive credit of payments though the mode indicated above. Notwithstanding my/our choice of mode edsave Healthcare (TPA) Ltd reserves the right to issue a cheque / credit the account in the mode that they may deem fit. I/We would not hold edsave Healthcare (TPA) Ltd responsible, if the transaction is delayed or not effected at all or credited to an incorrect account for reasons of incomplete /incorrect information. Signature of Applicant Place: ate For Office Use: Reference No: Bank etails verified by: etails captured in System on: etails captured in System verified And found correct: Signature of Officer Name & esignation ate:
ID: 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 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 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 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 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. 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
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 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 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 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 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 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 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 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 the Insured The issue of this form is not to be
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 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 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 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 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 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 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 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 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 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 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 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 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 informationHRMD CIRCULAR NO Medical Insurance Scheme for Retired Officers/Retired employees Operational Guidelines
Human Resources anagement ivision (Hospitalisation Cell), Head Office: New elhi Phone No. 011 26174730 Email hrdhospitalisation@pnb.co.in FAX 011 26196491 arch 11, 2016 TO ALL OFFICES HR CIRCULAR NO. 300
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 informationM/S.NATCO PHARMA LTD.
/S.NATCO PHARA LT. UNITE INIA INSURANCE COPAN LIITE Policy No : 052100/28/15/P112796862 Policy Start ate-21/01/2016 Policy End ate 20/01/2017 2/18/2016 1 India Health Care Services ( TPA ) Pvt Ltd Contents
More informationC I R C U L A R. For Reimbursement claims of Hospitalization / Domiciliary Hospitalization/ Domiciliary treatment expenses:
ALLAHABA BANK PERSONNEL AMINISTRATION EPARTMENT (HUMAN RELATIONS SECTION) Head Office : 2, Netaji Subhas Road, Kolkata 700 001 Instruction Circular. 13993/AMN(HR)/2015-2016/20 ate : 06-11-2015 To ALL OFFICES
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 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 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 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 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 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 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 informationFrequently Asked Questions (FAQs)
Mediclaim Policy for Ex Employees of RITES Frequently Asked Questions (FAQs) 1. What is Mediclaim policy? A mediclaim insurance policy ensures that your and your family s medical expenses are borne, or
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 LIMITE (IRA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LT] Plot no.a-442, Road No-28,M.I..C Indurial Area, Wagale Eate, Ram
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 informationIssuance of this form does not amount to admission of any liability of under the policy on the part of the insurers
The Oriental Insurance Company Limited HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM Claim Number Issuance of this form does not amount to admission of any liability of under
More informationHealth Insurance Benefit plan Monster.com India Pvt Ltd. Family Health Plan (TPA) Limited. Hyderabad
Health Insurance Benefit plan 2016 2017 Monster.com India Pvt Ltd. Family Health Plan (TPA) Limited Hyderabad Medical Benefit Coverage Details Enrolment in the program Cashless Process Non-Cashless Claims
More informationHealth Benefit plan EXCERS TECHNOLOGIES PVT LTD Family Health Plan (TPA) Limited. Hyderabad
Health Benefit plan 2017 2018 EXCERS TECHNOLOGIES PVT LTD Family Health Plan (TPA) Limited Hyderabad Hospitalization Insurance Cover Insurer: The Bharti Axa General Ins. Co. Ltd Coverage: 27 January 2017
More informationHDFC ERGO General Insurance Company Limited
HFC ERGO General Insurance Company Limited INIVIUAL PERSONAL ACCIENT - CLAIM FORM Claimant s Statement INSURE INFORMATION Form A ate of Bir: Phone. (Off): Name and address of employer: M M Marital Status:
More informationCLAIM FORM. Particulars Claim 1 Claim 2 Claim 3 Claim 4
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD. 302, Lalita Towers, Behind Railway Station, Near Hotel Rajpath Dinesh Mills Road, Vadodara- 390 005 (Gujarat). UAN Voice No. 1860-233-4446. UAN Fax No. 1860-233-4447
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 informationEMPLOYEE INSURANCE POLICY. Group Personal Accident Insurance Policy
EMPLOYEE INSURANCE POLICY Group Mediclaim Policy Group Personal Accident Insurance Policy Policy effective 7 th December 12 Objective To support employees in their immediate and long term needs by providing
More informationPersonal Accident. Claim Form. Important Notes
Personal Accident Claim Form Important Notes This claim form is to facilitate your claim in the event of you or a member of your family is confined to hospital while being Insured under a Personal Accident
More informationDEATH CLAIM FORM (DCF) CLAIMS DOCUMENT CHECKLIST (CDCL)
DEATH CLAIM FORM (DCF) CLAIMS DOCUMENT CHECKLIST (CDCL) Life Assured Name: Policy No.: Please submit this form along with the requirements mentioned below at the nearest branch or address mentioned overleaf
More informationEasy Travel. Claim Form.
Issuance of this form does not amount to admission of any liability or a waiver of any of the terms and conditions of the insurance contract. If any claim is in any manner dishonest or fraudulent, or is
More informationEasy Travel Insurance CLAIM FORM
Easy Travel Insurance Apollo Munich Health Insurance Co. Ltd. 10th Floor, Tower-B, Building No. 10, CLAIM FORM Issuance of this form does not amount to admission of any liability or a waiver of any of
More informationDCB Vehicle Loan Application Form
CB Vehicle Loan Application Form Commercial Vehicle Loan New Vehicle Loan Vehicle Re-Finance Loan Auto Loan Used Vehicle Loan New Vehicle Body Loan Application No. Application ate: Please complete the
More informationHDFC ERGO General Insurance Company Limited
GROUP PERSONAL ACCIENT CLAIM FORM Claimant s Statement Form A ate of Birth: Name and address of employer: M M Marital Status: Married Unmarried Insured s Occupation: oes the insured have any other insurance?
More informationCLAIM FORM. Particulars Claim 1 Claim 2 Claim 3 Claim 4
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD. 18/13, WEA, Ground Floor, Ganga Plaza, Pusa Lane, Karol bagh, New Delhi - 110 005 UAN Voice No. 1860-233-4446. UAN Fax No. 1860-233-4447 E-mail ID: delhi@mdindia.com.
More informationTata AIA Life Insurance Company Limited (hereinafter called the Company ) DEATH CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT
Tata AIA Life Insurance Company Limited (hereinafter called the Company ) DEATH CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT Guidelines / Notes: 1. Death benefit is payable subject to policy being inforce
More informationNew Update (Mandatory for KYC update request) Normal Simplified (for low risk customers) Small. Unmarried
CENTRAL KYC REGISTRY Know Your Customer (KYC) Application Form Individual Important Instructions: A) Fields marked with * are mandatory fields. B) Please fill the form in English and in BLOCK letters.
More informationTRAVEL INSURANCE (BUSINESS AND HOLIDAY) Claim Form
SBI General Insurance Company Limited IRDA Reg. No. 144 dated 15/12/2009 CIN: U66000MH2009PLC190546 TRAVEL INSURANCE (BUSINESS AND HOLIDAY) Claim Form Call (Toll Free) 1800 22 1111 1800 102 1111 www.sbigeneral.in
More informationPARTICULARS OF POLICYHOLDER / INSURED PERSON / CLAIMANT (to be completed for all claims) NRIC/Passport No.
Travel Claim Form The acceptance of this Form is NOT an admission of liability on the part of HL Assurance Pte. Ltd.. Any documentary proof or report required by HL Assurance Pte. Ltd. shall be furnished
More informationReliance Wealth + Health Plan
Reliance Wealth + Health Plan CLAIM FORM HOSPITAL CASH BENEFIT (To be filled in block letters by the Claimant/Principal Insured) Please answer all questions carefully. Also attach the copy of the health
More informationKNOW YOUR CLIENT (KYC) APPLICATION FORM (For Individuals) Annexure 1
Photograph KNOW YOUR CLIENT (KYC) APPLICATION FORM (For Individuals) Annexure 1 Please affix your recent passport size photograph and sign across it Please fill this form in ENGLISH and in BLOCK LETTERS.
More informationCorporate Travel Claim Form
Corporate Travel Claim Form Important Notice The acceptance of this Form is NOT an admission of liability on the part of Zurich Insurance Company Ltd (Singapore Branch) (the Company ). Any documentary
More informationCyberSmart. Claim Form. Important Notes
CyberSmart Claim Form Important Notes This claim form is to facilitate your claim in the event of you, a spouse or a dependent who is a named insured, has incurred expenses which falls within the definition
More informationMEDICLAIM CARD DOWNLOAD & IMPORTANT INFORMATION ABOUT MEDICLAIM POLICY
MEDICLAIM CARD DOWNLOAD & IMPORTANT INFORMATION ABOUT MEDICLAIM POLICY Our Group Mediclaim Policy has been renewed through The Oriental Insurance Company Limited and TPA is Paramount Health Services (PHS).
More informationAmerican Express Cardmember / Business Travel
American Express Cardmember / Business Travel Claim Form The information requested and supporting documents required for your claim are detailed below each section. Further documents or information may
More informationSWAVALAMBAN National Pension System (NPS)
Form 503 Page 1 SWAVALAMBAN National Pension System (NPS) Withdrawal of Accumulated Pension Wealth by Claimant due to the death of the subscriber (Please fill all the details in CAPITAL LETTERS & in BLACK
More informationClaim Form - Travel Insurance
Claim Form - Travel Insurance Important tice: To enable us to process your claim, please submit the duly completed claim form with supporting documents in original as listed in the subsequent section.
More informationForm 103-GD Page 1 National Pension System (NPS)
Form 103-GD Page 1 National Pension System (NPS) Withdrawal of Accumulated Pension Wealth by Claimant due to the death of the subscriber (Please fill all the details in CAPITAL LETTERS & in BLACK INK only.)
More informationLIFE INSURANCE CORPORATION OF INDIA (Established by the Life Insurance Corporation Act, 1956)
Annexure I Form No. 470 (Rev.) PHOTO LIFE INSURANCE CORPORATION OF INDIA (Established by the Life Insurance Corporation Act, 1956) Varishtha Pension Bima Yojana Plan No. 828 (UIN: 512G291V01) For Office
More informationForm DVAT 04 Cover Page
Department of Value Added Tax Government of NCT of Delhi Form DVAT 04 Cover Page (See Rule 12 of the Delhi Value Added Tax Rules, 2005) Application for Registration under Delhi Value Added Tax Act, 2004
More information2. Details of the Claimant if different than the Life Assured (To be filled by person entitled to receive claim proceeds under the policy):
CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT (CRITICAL ILLNESS RIDER / MAJOR SURGERY ASSISTANCE RIDER ) (Format : AP) Guidelines/ Notes: 1. The benefit is payable subject to the policy being inforce on
More informationProtect the future of your employees and their families
GROUP HEALTH INSURANCE Protect the future of your employees and their families PROTECT THE FUTURE OF OUR EMPLOEES AND THEIR FAMILIES A mutual relationship always exists between an employer and an employee.
More informationCustomer Guide Book. EasyHealth
Customer Guide Book EasyHealth Apollo Munich Health Insurance Company Limited (AMHI) congratulates you on your health insurance choice and welcomes you into the select group of Easy Health policyholders.
More informationCLAIM FORM FOR PERSONAL ACCIDENT INSURANCE
CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE (The issuance of this form is not to be taken as an Admission of Liability) Address to dispatch Claim Documents : ICICI Lombard Health Care ICICI Bank Tower,
More informationRAFFLES SHIELD CLAIM FORM
RAFFLES SHIELD CLAIM FORM IMPORTANT NOTES: It is important to read the notes below before you complete the claim form. PREPARING REQUIRED DOCUMENTS Please complete this form in FULL and submit the following
More informationOverseas Secondment. Claim Form. Important Notes
Overseas Secondment Claim Form Important Notes To facilitate the processing of your claim, you are required to complete Sections A, B and C for all claim submissions. The issue and acceptance of this form
More information(To be filled by Participant)
ANNEXURE J Participant Name, & DP Id (Pre-printed) APPLICATION FOR OPENING AN ACCOUNT (For Individuals Only) Client Id Date : (To be filled by Participant) I/We request you to open a depository account
More informationSECTION 1 (To be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old)
C041017 PruCustomer Line: 1800-333 0 3333 CRISIS COVER CLAIM FORM Kidney Failure / Surgical Removal of One Kidney / Chronic Kidney Disease Major Organ (Kidney)Transplantation Important tes 1. Please note
More informationFAQs Health Claims. Page 1 of 7
FAQs Health Claims Index FAQs Related To Questions Page Number (From & To) General Claim Intimation Q 1 2 Cashless Claims Q2 To Q4 2 3 Reimbursement Claim Q5 To Q7 3 Claim Settlement Turnaround Time Q8
More informationPERSONAL ACCIDENT OR SICKNESS CLAIM FORM
PERSONAL ACCIDENT OR SICKNESS CLAIM FORM This form must be completed truthfully and accurately. The list of documents required is not exhaustive and we reserve our right to request from you any additional
More informationThis is to certify that following are the family members under (HUF) S. No. Name Gender (Male/Female) Relationship with Karta PAN No./ Birth Certificate No.* Date of Birth 1. D D M M Y Y Y Y 2. D D M M
More informationHDFC ERGO General Insurance Company Limited
HFC ERGO General Insurance Company Limited GROUP PERSONAL ACCIENT CLAIM FORM Claimant s Statement INSURE INFORMATION Form A ate of Bir: Phone. (Off): Name and address of employer: M M Marital Status: Married
More informationPART I (To be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old)
C011017 PruCustomer Line: 1800-333 0 3333 HOSPITAL CARE BENEFIT CLAIM FORM (PRUSMART LADY & PRULADY) Important tes 1. Please note that, under the policy terms and condition, the policy may be void if any
More informationGrab. Prolonged Medical Leave Insurance Claim Form. Important Notes
Grab Prolonged Medical Leave Insurance Claim Form Important Notes This claim form is to facilitate your claim in the event of you or a member of your family is Insured under a Personal Accident policy.
More informationSection A Subscriber s Personal Details:
Form 302 Page 1 New Pension System (NPS) Withdrawal Form for Claim of Accumulated Pension Wealth by Subscriber before attaining 60 years of age (Please fill all the details in CAPITAL LETTERS & in BLACK
More informationHDFC ERGO General Insurance Company Limited
HDFC ERGO General Insurance Company Limited Overseas Travel Insurance Claim Form (To be filled in by the Insured Policyholder or Insured s Representative duly authorised by Power of Attorney. Issuance
More informationCLAIM INTIMATION FORM INDIVIDUAL LIFE POLICIES
Instructions for filling up the form CLAIM INTIMATION FORM 1. Please fill this form in BLOCK LETTERS using black or blue ink. 2. This form must be filled by the CLAIMANT only. If the Claimant does not
More informationWithdrawal Form for Claim of Accumulated Pension Wealth by Claimant(s) due to death of the subscriber
Form 303 Page 1 New Pension System (NPS) Withdrawal Form for Claim of Accumulated Pension Wealth by Claimant(s) due to death of the subscriber (Please fill all the details in CAPITAL LETTERS & in BLACK
More informationTHE ORIENTAL INSURANCE COMPANY LIMITED Regd. Office: Oriental House, A-25/27, Asaf Ali Road, New Delhi
THE ORIENTAL INSURANCE COMPANY LIMITED Regd. Office: Oriental House, A-25/27, Asaf Ali Road, New Delhi 110 002. Issuing Office HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM
More informationAIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM
AIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM Important Notes: 1) AIA HealthShield Gold claims for Singaporeans and Permanent Residents must be submitted electronically via the medical institutions
More informationSHRAVAK AROGYAM PHASE-II
FREQUENTLY ASKED QUESTIONS 1. About JIO? JIO is a vibrant organization for total unity of Jains, to serve all living beings & bring all round progress. JIO intends to be the global organization of visionaries
More informationSection A Subscriber s Personal Details:
Form 301 Page 1 New Pension System (NPS) Withdrawal Form for Claim of Accumulated Pension Wealth by Subscriber on attaining 60 years of age (Please fill all the details in CAPITAL LETTERS & in BLACK INK
More informationHEALTH INSURANCE GUIDE BOOK FOR SERVICING LIC S EMPLOYEES POLICY
Page1 HEALTH INSURANCE GUIDE BOOK FOR SERVICING LIC S EMPLOYEES POLICY Vidal Health TPA Pvt. Ltd., Tower No. 2, First Floor, SJR I Park, EPIP Area, Whitefield, Bangalore-560 066 Toll free number - Kerala:1800
More informationRequest for converting Resident Indian Savings Bank (SB) account into NRO SB account
FOR BRANCH USE: Branch Name/ Code: Receipt Date: / / Action Taken on: / / Signature Request for converting Resident Indian Savings Bank (SB) account into NRO SB account NRI-1.3 Account No: Account Holder
More informationNCT Check List for CRMF Unit
NCT Check List for CRMF Unit (1) Change of Address: 1. Request letter signed as per the mode of holdings. 2. Proof of Identity: Only PAN card copy shall be considered if PAN is updated in the folio or
More informationProperty. Claim Form. Important Information
Property Claim Form Important Information The information requested and documents mentioned in this form are a general guide. Further documents or information may be required depending on the circumstances
More informationSECTION 1 (To be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old)
C041017 TERMINAL ILLNESS CLAIM FORM PruCustomer Line: 1800-333 0 3333 Important tes 1. Please note that, under the policy terms and conditions, the policy may be void if any information provided in this
More informationName of Examination Year and month in which. Examination was held. Serial No. in Merit list. 1. The holder of this card, Shri/Smti/Kumari
D:\Higher~1\HighL.pm5 page No. 27 No.... ANNEXURE - II LAST DATE OF SUBMISSION OF FORMS 10-8-2012 ENTITLEMENT CARD GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION
More information