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    Pages From Claim Form - New Reimbursement Form A+B-3

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    NagLakshmanan
    This claim form is for health insurance policies other than travel and personal accident. It requests details about the primary insured such as name, address, policy number, and insurance history. It also requests information about the insured person who was hospitalized, including name, gender, age, relationship to primary insured, and occupation. Finally, it requests details about the hospitalization, including dates of admission/discharge, treating doctor, diagnosis, and system of medicine. The form is to be filled in by the insured for submitting a claim.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Pages From Claim Form - New Reimbursement Form A+B-3

    Uploaded by

    NagLakshmanan
    64 views1 page
    This claim form is for health insurance policies other than travel and personal accident. It requests details about the primary insured such as name, address, policy number, and insurance history. It also requests information about the insured person who was hospitalized, including name, gender, age, relationship to primary insured, and occupation. Finally, it requests details about the hospitalization, including dates of admission/discharge, treating doctor, diagnosis, and system of medicine. The form is to be filled in by the insured for submitting a claim.

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    Pages from Claim Form -New Reimbursement Form A+B-3

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    This claim form is for health insurance policies other than travel and personal accident. It requests details about the primary insured such as name, address, policy number, and insurance history. It also requests information about the insured person who was hospitalized, including name, gender, age, relationship to primary insured, and occupation. Finally, it requests details about the hospitalization, including dates of admission/discharge, treating doctor, diagnosis, and system of medicine. The form is to be filled in by the insured for submitting a claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    64 views1 page

    Pages From Claim Form - New Reimbursement Form A+B-3

    Uploaded by

    NagLakshmanan
    This claim form is for health insurance policies other than travel and personal accident. It requests details about the primary insured such as name, address, policy number, and insurance history. It also requests information about the insured person who was hospitalized, including name, gender, age, relationship to primary insured, and occupation. Finally, it requests details about the hospitalization, including dates of admission/discharge, treating doctor, diagnosis, and system of medicine. The form is to be filled in by the insured for submitting a claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Bajaj Allianz General Insurance Company Limited.

    Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006
    Email id: [email protected] Relationship Beyond Insurance
    Toll free no:1800-209-5858
    020-30305858
    (To be filled in block letters)

    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 an admission of liability
    DETAILS OF PRIMARY INSURED
    a) Policy No: b) Sl. No/Certificate No:
    c) Company TPA ID No: d) Customer ID:
    e) Company Name:__________________________________________________________f) Employee No:___________________________

    SECTION A
    g) Name:
    h) Address:

    City: State: Pin Code:


    Phone No: Email ID:__________________________________________________________
    DETAILS OF INSURANCE HISTORY
    a) Currently covered by any other Mediclaim / Health Insurance Yes No
    b) date of commencement of first insurance without break
    c) If yes, company name: Policy No:

    SECTION B
    Sum Insured (Rs.):
    d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date: D D M M Y Y Y Y
    Diagnosis
    e) Previously covered by any other Mediclaim / Health Insurance: Yes No
    f) If yes, Company Name

    DETAILS OF INSURED PERSON HOSPITALIZED


    a) Name of the Patient: _______________________________________________________________________________________________
    b) Health ID card no of the Patient:______________________________________________________________________________________
    c) Gender: Male Female d) Age: years months e) Date of Birth D D M M Y Y Y Y

    SECTION C
    f) Relationship of Primary insured: Self Spouse Child Father Mother Other (Please Specify)
    g) Occupation: Service Self Employed Homemaker Student Retired Other (Please Specify)
    h) Address (if different from above) _____________________________________________________________________________________
    City: State: Pin Code:
    I) Phone No: J) Email ID: ________________________________________________________

    DETAILS OF HOSPITALIZATION
    a) Name of Hospital where Admitted: ____________________________________________________________________________________
    b) Room Category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room
    c) Hospitalisation due to: Injury Illness Maternity
    SECTION D

    d) Date of Injury/Date Disease first detected/Date of Delivery: D D M M Y Y Y Y


    e) Date of admission D D M M Y Y Y Yf) Time: H H: M M g) Date of Discharge D D M M Y Y Y Yh)Time: H H M M
    I) Name of treating doctor_____________________________________Diagnosis________________________________________________
    j) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse /Alcohol Consumption
    i) If Medico legal: Yes No ii) Reported to police: Yes No
    iii) MLC report and Police FIR attached: Yes No j) System of Medicine

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