Regd. Office: Oriental House, P.B. No.7037, A-25/27, Asaf Ali Road, New Delhi- 110 002 Issuing Office
HOSPITALISATION & DOMICILIARY HOSPITALISATION BENEFIT CLAIM FORM Claim No.___________________________ Issuance of this form does not amount to admission of any liability under the claim on the part of the Insurance. Please give the following information correctly and completely to enable the Company to process your claim promptly. For Office use only 1. Name of the Insured (In wohole name policy is issued) 2. Details of the Insured Person (In respect of whom claim is made) (a) Name & relationship with the Insured Present completed age Occupation Residential address SURNAME INITIAL
(b) (c) (d)
3. Policy No. 4. Nature Disease/illness contracted or suffered 5. Date of sustained Disease/illness detected of injury injury or first
a) Name & Address of the attedning Medical Practitioner :
_________________________________ ________________Pin Code__________ State/U. Territory
(b) Qualification & Telephone No.
(c) Registration No. 6. (a) Name and Addres of the Hospital/Nursing Home/Clinic : ____________________________ _______________Pin Code______ State/U.Territory Date Date Month Month Year Year
(b) Date of Admission (c) Date of Discharge 7. If the claim is for Domicilliary Hospitaliation Please indicate (a) Date of Commencement of treatment (b) Date of completion of treatment (c) Name & Address of attending Medical Practitioner (d) Telephone No. (e) Registration No.
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 4) 1. 2. 3. 4. 5. 6. 7. 8.... [continues]
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