NIC Claim Form

Claim No.

NATIONAL INSURANCE COMPANY LIMITED
Registered & Head Office : 3, Middleton Street, Kolkata 700 071.

Hospitalisation And Domiciliary Hospitalisation Benefit Policy
CLAIM FORM
Issuance of this Form does not amount to admission of any liability under the claim on the part of the insurers. YOU ARE ADVISED TO FILL EACH AND
EVERY COLUMN OF THIS CLAIM FORM and give all information correctly and completely to enable theTPA company to process your claim promptly

PARAMOUNT HEALTH SERVICES PVT LTD (IRDA License No. 006)
Elite Auto House, 54-A, 2nd Floor, M. Vasanji Road, Mumbai – 400 093 Tel: 022 – 5662 0808. Fax: 022 – 28259743

1. Name of the Insured : _________________________________________________________________________
(In whose name policy is issued ) (SURNAME)
(NAME)
(FATHER'S / HUSBAND'S NAME)
2. Details of the insured person (in respect of whom claim is made)
a)

Name & relationship to the insured : _________________________________________________________

b)

Present completed Age

: _________________________________________________________

c)

Occupation

: _________________________________________________________

d)

Residential Address

: _________________________________________________________

e)

Telephone Number

: _________________________________________________________

f)

E-Mail Address

: _________________________________________________________

3. Policy No. in Full
Policy Period
4. Nature of Disease/ Illness contracted
Or Injury suffered
5. Date of injury sustained or Disease/
Illness first detected
6. a)

: _________________________________________________________
: From _________________ To _________________
: _______________________________________
___ ___
(Date)

___ ___
(Month)

___ ___ ___ ___
(Year)

Name & Address of the attending
Medical Practitioner
_________________________________________________________
_________________________________________________________

b)

Qualification & Telephone No.