HDFC ERGO General Insurance Company Limited

Transcription

1 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: Married Unmarried Phone.(Res): Insured s Occupation: oes e insured have any oer insurance? es If yes, please li all companies, type of insurance, policy numbers and insurance amounts: ate of accident: M M Time and place accident occurred: Please describe in detail e circumances of accident: Was e accident related to e Insured s occupation? es Please describe e nature of Insured s injuries: Please li e names and addresses of all treating physicians and hospitals: id police or oer auorities inveigate e accident? es If yes, please provide name, address and telephone number of all inveigating officers and agencies: Claimant s Name: Claimant s Address: CLAIMANT INFORMATION (If different an Insured Information above) Relationship to Insured: Age: rs Phone. (Off): Phone.: In what capacity are you making is claim? AUTHORIZATION I auorize any insurance company, physician, hospital or oer healcare provider, or any oer organization, initution or person at may have records, documents or knowledge regarding e insured to release any information requeed regarding is claim and e loss reported. I underand is information will be used by HFC ERGO General Insurance, or its auorized representatives, for e purpose of evaluating and determining coverage for is claim. I know I have a right to receive a copy of is auorization upon reque and agree at a photographic or facsimile copy of is auorization is as valid as e original. I agree at is auorization shall be valid for e duration of is claim. I underand at any person who knowingly and wi intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. ate: M M SIGNE(Claimant or auorized person) Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.

2 HFC ERGO General Insurance Company Limited ACCIENTAL INJUR - CLAIM FORM Insured s Statement INSURE INFORMATION Form B Phone. (Off): Phone.(Res): ate of accident: M M Time and place accident occurred: Please describe in detail e circumances of accident: Was e accident related to e Insured s occupation? es Please describe e nature of Insured s injuries: Please li e names and addresses of all treating physicians and hospitals: id police or oer auorities inveigate e accident? es If yes, please provide name, address and telephone number of all inveigating officers and agencies: Please li e names and addresses of all treating/consulting physicians or oer healcare providers: Name: Street Address: City: State: PinCode: Phone: If hospitalized, please provide name and address of hospital(s) where treatment was received: o you have any oer insurance at may provide coverage for is accident or loss? es If yes, please identify name, address, and policy number of all oer insurance: AUTHORIZATION I auorize any insurance company, physician, hospital or oer healcare provider, or any oer person who may have knowledge regarding is claim to release any information requeed regarding is claim and e loss reported. I underand is information will be used by HFC ERGO General Insurance, or its auorized representatives, for e purpose of evaluating and determining coverage for is claim. I know I have a right to receive a copy of is auorization upon reque and agree at a photographic or facsimile copy of is auorization is as valid as e original. I agree at is auorization shall be valid for e duration of is claim. I underand at any person who knowingly and wi intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. ate: M M Signed (Insured or auorized person) CERTIFICATION OF NO OTHER INSURANCE I, hereby certify at I have no oer accident or heal insurance or any oer insurance covering is loss. ate: M M Signed (Insured or auorized person) Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.

3 HFC ERGO General Insurance Company Limited HOSPITAL CASH PLAN - CLAIM FORM (N.B. To be filled in by e Insured Policy holder, or Insured s auorised representative enjoying power of attorney. Issuance of is claim form is not be taken as admission of liability) Form C Name of Policy holder: Name of Employee/Member: (For group insurance policy only) INSURE INFORMATION Name of Patient: Occupation: Insured./Certificate. (If applicable): I.. Card.: ate of Bir: M M Relationship to e Policy holder: Self Spouse Child Staff/ Member ependent 1. Have you had any prior treatment for is or related conditions? es es octor s Name: Address: ate: M M 2. Are you making any oer insurance claim as a result of is hospitalization/surgery? Name of Insurance Company: es es 3. (a) Was e hospitalization/surgery a result of an accident? (b) ate of accident: es es M M Time and place accident occurred: Please describe in detail e circumances of accident: 4. Hospitalization Name of hospital: ate of admission: M M ate of ischarge: M M I/We e above named, do hereby, to e be of my/our knowledge and belief, warrant e tru of e foregoing atement in every respect, and I/We agree if I/We have made, or in any furer declaration e Company may require in respect of e said claim, shall make any false or fraudulent atement, or any suppression or concealment e Policy shall be void and all rights to recover ereunder in respect of pa or future claims shall be forfeited AUTHORIZATION I HEREB AUTHORIZE on behalf of e patient: (1) Any employer, medical practitioner, hospital, clinic, insurance company, bank, government initution, or oer organisation, initution or person, at has any records or knowledge of e patient and/or who has attended or may hereafter attend e patient to disclose such information to HFC ERGO General Insurance Company; (2) HFC ERGO General Insurance Company or any of its appointed medical examiners or laboratories to perform e necessary medical assessment and tes to evaluate e heal atus of e patient in relation to is claim. This auorization shall bind e patients successors and remains valid notwianding dea or incapacity. A photocopy of is auorization shall be as valid as e original. ate: M M Signature of Patient Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.

4 HFC ERGO General Insurance Company Limited ACCIENTAL INJUR - CLAIM FORM Accidental Injury Hospital Cash Claim (Accident or Sickness) Attending Physician s Statement INSURE INFORMATION Form ate of Bir: Phone. (Off): Name and address of employer: M M Marital Status: Married Unmarried Phone.(Res): Insured s Occupation: ate of accident: M M ate of fir treatment: M M Please describe in detail e nature of e Insured s injuries: Was e accident related to e Insured s occupation? es Was e Insured hospitalized? es If yes, please li e names and addresses of all hospitals and all admission/discharge dates: id e Insured have any injury or illness prior to e accident at contributed to e accident or to e Insured s present condition? es If yes, please describe: Were any surgical procedures performed? es If yes, please li all procedures, and dates performed: What are e Insured s current subjective symptoms? What are e objective findings? (please include results of current x-rays, labtes, etc.)? ates of total disability: From: ates of partial disability: From: ate Insured able to return to work: M M M M M M Was e Insured seen by any oer physician? es If yes, please li e names and addresses of all oer physicians: To: To: M M M M Name of Attending Physician: ATTENING PHSICIAN INFORMATION Phone.: I underand at any person who knowingly and wi intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. ate: M M SIGNE (Attending Physician) Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.

5 HFC ERGO General Insurance Company Limited ACCIENTAL INJUR - CLAIM FORM Accidental ea Claimant s Statement INSURE INFORMATION Form E ate of Bir: Phone. (Off): Name and address of La Employer: M M Marital Status: Married Unmarried Phone.(Res): Insured s Occupation(at time of dea): id e Insured have any oer accident or life insurance? es If yes, please li all companies, policy numbers and insurance amounts: ate of accident: M M Time and place accident occurred: Please describe in detail e circumances of accident: Was e accident related to e Insured s occupation? es Please describe e cause of e Insured s dea: Please li e names and addresses of all treating physicians and hospitals: id police or oer auorities inveigate e accident? es If yes, please provide name, address and telephone number of all inveigating officers and agencies: Was an autopsy performed? es If yes, please provide name and address of Medical Examiner: Was a coroner s inque held? es If yes, what was e determination? Claimant s Name: Age: rs Relationship to Insured: Claimant s Address: CLAIMANT INFORMATION Phone. (Off): Phone.(Res): In what capacity are you making is claim? Beneficiary Executor* Adminirator* Guardian* Truee* Assignee* *Please provide a certified copy of all documents supporting your auority (e.g., Succession Certificate, tarised Affidavit, tarised will, etc.)i auorize any insurance company, physician, hospital or oer healcare provider, or any oer organization, initution or person at may have records, documents or knowledge regarding e insured to release any information requeed regarding is claim and e loss reported. I underand is information will be used by HFC ERGO General Insurance, or its auorized representatives, for e purpose of evaluating and determining coverage for is claim. I know I have a right to receive a copy of is auorization upon reque and agree at a photographic or facsimile copy of is auorization is as valid as e original. I agree at is auorization shall be valid for e duration of is claim. I underand at any person who knowingly and wi intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. ate: M M SIGNE(Claimant or auorized person) Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.

6 HFC ERGO General Insurance Company Limited Individual Personal Accident Claim ocument Checkli (Additional documents if required will be requeed by e insurer) Accidental Hospitalization uly filled and signed Claim Form FIR Copy Hospital Indoor Case Papers ischarge Card Hospital Bills, Medicine Bills, Prescriptions Passport, PAN Card, Aadhar card and Address Proof (KC ocuments) Personal Accident - ea uly filled and signed Claim Form FIR Copy Po Mortem Report Cause of dea Certificate from treating doctor ea Certificate Passport, PAN Card, Aadhar card and Address Proof (KC ocuments) Personal Accident Permanent isability uly filled and signed Claim Form FIR Copy isability Certificate from treating doctor Hospital Indoor Case Papers Passport, PAN Card, Aadhar card and Address Proof (KC ocuments) * Please send e cancelled cheque of insured /nominee for NEFT / RTGS transfer. If claim becomes payable. Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.

7 HFC ERGO General Insurance Company Limited Consent for Mode of Claim Payment Name of Insured Policy Number Claim Number Beneficiary Name Mode of Payment Cheque Fund Transfer (Please tick for mode of payment) Insured s Name as per Bank Account Bank Account Number (All Fields are Mandatory in case of Fund Transfer) Branch Name IFSC Code address Attachments In Support of Bank etails (Please tick e type of proof submitted) Cancelled Cheque Bank Passbook Copy eclaration: I Mr./ Mrs/ Ms. undersigned, legal beneficiary of e above claim, declare at all details mentioned in is form are true and I agree to e mode of payment again e particular claim number mentioned above. Signature of Beneficiary Stamp Required in case of Company ate: M M Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg. 125.