The claim formats are placed below:

PROCEDURE FOR CLAIM: The members are requested to submit their claims directly to the Insurance Company. The address and other details of the Insurance Company are as follows: THE DIVISIONAL MANAGER M/s.THE NEW INDIA ASSURANCE COMPANY LIMITED 49-01-09, II FLOOR, DALI RAJU SUPER MARKET SANGAM OFFICE BUS STOP, AKKAYYAPALEM MAIN ROAD VISAKHAPATNAM 530 016 Dealing Officer: Sri K Gowri Shankar Rao, Admn.Officer, Cell No.7702398801 Phone No.0891-2517737, 2591977, FAX No.0891 2517781 e-mail: nia_620300@yahoo.com Higher Authority: Dr P. Manmadha Rao, Sr.Divisional Manager Cell No.9848190890 For the convenience of settlement of your claim (reimbursement /payment), members may avail the services through Electronic Clearing service(ecs) and are advised to fill in the details your Bank Account No: IFSC Code No:, Name of the Bank :Branch Name Place: in the claim forms. Kindly make a note that as and when there is a change in the mailing address, the same may be intimated to Personnel Dept.-Welfare Section of RINL/ VSP and also to the Insurance Company along with the Telephone Number to enable us to communicate with you promptly. The claim formats are placed below: i) Claim Intimation letter.... Annexure I ii) Hospitaliszation and Domicilliary hospitalization Benefit Policy Claim Form.. Annexure-II iii) O P D Treatment claim Form.. Annexure- III

To CLAIM INTIMATION LETTER The Divisional Manager Divisional Office :III (620300) Tied Unit Annexure-I to Mediclaim policy Date : Dear Sir, Sub : Mediclaim Index No. (MIN) Ref : Mediclaim Policy No. This is to inform you that I have been admitted to Hospital, details of which are as under : 1. Name of the Insured Member : 2. Name of the injury/illness : 3. Name & Address of Hospital : 4. Date of Admission in Hospital : Thanking you, Yours faithfully, Name : Full Address for Correspondence : Phone/Cell No.

Divisional Office:III (620300) Tied Unit Annexure II to Mediclaim policy HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM Claim No. (for office use only) Please fill in all columns without exception put NA, wherever the column is not relevant. 1. Name of the insured : (Surname) (Name) 2. Details of the person Undergoing treatment : a) Name : b) Date of Birth : c) Occupation, if any. : d) Residential address: (in capital letters) e) Phone No. : 3. MIN No./Mediclaim Policy No.: 4. Nature of Disease/Illness/Injury suffered : 5. a) Name & Address of the Hospital/ Nursing Home : b) Date of Admission : c) Date of Discharge :

6. If the claim is for Domiciliary Hospitalization, please indicate : a) Date of commencement of treatment: b) Date of completion of treatment : c) Name & Address of the attending Medical Practitioner : I have incurred on the treatment of Disease/Illness/Accident referred to above, the expenses as per the details given by me in the Schedule of expenses given overleaf. In support of the above claim, I enclose the following documents : (please indicate by tick) : 1. Bill, Receipt and Discharge Certificate/Card from the Hospital. 2. Cash Memos from the Hospital/Chemist(s) supported by proper prescription. 3. Pathological Test Reports 4. Surgeon s Certificate stating nature of operation performed. 5. Attending Doctor s/consultant s/specialist s/anesthetist s Report. 6. Discharge Voucher duly signed on Re.1/- Revenue Stamp. I hereby warrant the truth of the foregoing particulars in every respect. I further declare that, in respect of the above treatment, no benefits under any other scheme of insurance or from my present employer s, if any, have been claimed by me. Bank A/c No: IFSC Code No: Name of the Bank : Branch Code Place Note : All original documents should be enclosed. Photocopy will not be accepted. However, photocopy of the document submitted may be retained by the claimant. Date : Signature of the Claimant MIN NUMBER CLAIM NO.

Divisional Office, III (620300) Tied Unit SCHEDULE OF EXPENSES INCURRED BY THE CLAIMANT (Attach separate annexure for details of bills) Details of expenses claimed under hospitalization/domiciliary hospitalization (To be supported by bills/receipts/cash memos etc., 1. A) Pre hospitalization benefits (within 30 days prior to admission in hospital Amount claimed 2. A) Hospitalization benefits 3. Post-hospitalization benefits (Up to 60 days from date of discharge) Total Signature of claimant Date Place:

Divisional Office, III (620300) Tied Unit O.P.D. TREATMENT CLAIM FORM 1. Name of the Person : 2 Mediclaim Index No.(MIN) : (Employee Number in VSP) 2. Mediclaim Policy No. ; 3. Address (In Block Letters) : Annexure III to Mediclaim Policy 4. Phone No. with STD Code : 5. Nature of illness : 6. Period of illness : Expenses incurred Amount Bill No. Bill Date For Consultation a) b) For Medicines c) For Pathological and diagnostic Test I declare that the facts given are correct and that I have not claimed reimbursement for the above expenses incurred by me from any other source. Bank A/c No: IFSC Code No: Name of the Bank : Branch Code Place Place : Date: (Signature of the Insured) Please enclose the following documents along with the claims forms: a) Chemist/Nursing Home Bills/Receipts b) All pathological and other test reports and bills, if any * All the above documents should be in Original. Photocopies will not be accepted.

The members are advised to submit their claims directly to the Insurance Company. The address and other details of the Insurance Company are as follows: THE DIVISIONAL MANAGER M/s.THE NEW INDIA ASSURANCE COMPANY LIMITED 49-01-09, II FLOOR, DALI RAJU SUPER MARKET SANGAM OFFICE BUS STOP, AKKAYYAPALEM MAIN ROAD VISAKHAPATNAM 530 016 Dealing Officer: Sri K Gowri Shankar Rao, Admn.Officer, Cell No.7702398801 Phone No.0891-2517737, 2591977, FAX No.0891 2517781 e-mail: nia_620300@yahoo.com Higher Authority: Dr P. Manmadha Rao, Sr.Divisional Manager Cell No.9848190890 For the convenience of settlement of your claim (reimbursement /payment), members may avail the services through Electronic Clearing service(ecs) and are advised to fill in the details your Bank Account No: IFSC Code No:, Name of the Bank :Branch Name Place: in the claim forms. Kindly make a note that as and when there is a change in the mailing address, the same may be intimated to Personnel Dept.-Welfare Section of RINL/ VSP and also to the Insurance Company along with the Telephone Number to enable us to communicate with you promptly.