REIMBURSEMENT CLAIM FORM

TO BE FILLED IN BY THE INSURED

The issue of this form is not to be taken as admission of liability
DETAILS OF PRIMARY INSURED (To be filled in block letters)

a) Policy no: b) Sl. No/ Certificate No:

c) Universal Sompo Health Serve Card No:

d) Name:

SECTION A
e) 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 (`): d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date:

Diagnosis: e) Previously covered by any other Mediclaim/ Health Insurance : Yes No

f) If yes, Company Name :

DETAILS OF INSURED PERSON HOSPITALIZED

a) Name :

b) Gender : Male Female c) Age: years months d) Date of Birth:

e) Relationship to Primary Insured: Self Spouse Child Father Mother Other (Please specify)

f) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify)

SECTION C
g) Address (if different from above):

City: State:

Pin Code: Phone No: 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) Hospitalization due to: Injury Illness Maternity d) Date of injury/ Date Disease first detected/ Date of Delivery:

SECTION D
e) Date of Admission: f) Time: : g) Date of Discharge: h) Time: :

i) 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 & Police FIR attached: Yes No j) System of medicine:

DETAILS OF CLAIM
a) Details of treatment expenses claimed Claim Documents Submitted- Check List:

i. Pre Hospitalization Expenses ` ii. Hospitalization Expenses ` Claim FormDuly signed

iii. Post Hospitalization Expenses ` iv. Health Check up Cost ` Copy of the claim intimation, if any

v. Ambulance Charges ` vi. Others (code): ` Hospital Main bill

Total ` Hospital Break-up bill

vi. Pre hospitalization period: days vii. Pre hospitalization period: days Hospital Discharge Summary
SECTION E

b) Claim for Domiciliary Hospitalization: Yes No (if yes, provide details in annexure) Pharmacy Bill

c) Details of Lump sum / cash benefit claimed: Operation Theatre Notes

i. Hospital Daily Cash: ` ii. Surgical Cash: ` ECG

iii. Critical Illness Benefit: ` iv. Convalescence: ` Doctor's request for investigation

v. Pre/Post hosp. Lump sum benefit: ` vi. Others: ` Investigation Reports (including CT /
MRI / USG / HPE)
Total ` Doctor's Prescription

Others
 DETAILS OF BILLS ENCLOSED

Sl. No. Bill No. Date Issued By Towards Amount (`)

1 Hospital Main Bill
2 Pre hospitalisation Bills: ___ Nos
3 Post hospitalisation Bills: ___ Nos
4 Pharmacy Bills:

SECTION F
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN: b) Account Number:

SECTION G
c) Bank Name and Branch

d) Cheque/ DD Payable details: e) IFSC Code:

DECLARATION BY THE INSURED

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any
material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize Universal Sompo GIC Ltd, to seek necessary medical

SECTION H
information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the
purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.

Date: Place: Signature of the insured:

Registered Office: Universal Sompo General Insurance Co Ltd,Unit 401, 4th floor, Sangam Complex, 127, Andheri Kurla Road, Andheri East, Mumbai - 400059
Health Claims Management: Universal Sompo General Insurance Co Ltd, Assotech One, 5th Floor, C-20/1A, C –Block, Sector-62, Noida -201309
Toll Free Fax No: 1800 200 9134; Toll Free Helpline No: 1800 200 5142; Email ID: healthserve@universalsompo.com
Website: www.universalsompo.com; CIN# U66010MH2007PLC166770