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    Claim PG 1

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    barikunal2000
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    Claim PG 1

    Uploaded by

    barikunal2000
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    claim pg 1

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    claim pg 1

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    claim pg 1

    Copyright:

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

    Claim PG 1

    Uploaded by

    barikunal2000
    claim pg 1

    Copyright:

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

    STAR HEALTH AND ALLIED INSURANCE COMPANY LTD

    Reimbursement Claim Form - Part A

    Claim Number

    Claim Type

    Details of Proposer

    Policy Number Policy Period

    Proposer Name Customer ID


    Employee Name Employee ID No
    (in case of Group Policy) (in case of Group Policy)
    ID Proof No.
    ID Proof Type
    (Last 4 Digits if Aadhaar)
    CKYC Number PAN Card No.

    Address City

    Registered email ID District

    Registered Mobile No. State

    WhatsApp Number Pin code

    Details of Insured Patient in respect of whom claim has been made

    Insured Patient Name Gender


    Relationship with Proposer
    Date of Birth/Age
    / Employee
    ABHA ID No. ID Proof Type
    ID Proof No.
    Star Health / TPA ID Card No.
    (Last 4 Digits if Aadhaar)
    Hospitalisation Due to Illness Date (if accident) DD/MM/YYYY Time
    Reported to Police
    Place of Accident Yes No
    (if Accident)
    If not reported to Police
    give reasons

    Details of Insurance History

    Yes No

    If Yes, INSURER Name Policy Number

    Policy Period Sum Insured

    Yes No

    Page No: 1 of 4
    IRDAI Regn. No: 129
    Toll free Phone No: 1800 425 2255 | 1800 102 4477 CIN : L66010TN2005PLC056649

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