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    Rajanikant Pandey
    30 views3 pages

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    Copyright:

    © All Rights Reserved
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    30 views3 pages

    Claim Form

    Uploaded by

    Rajanikant Pandey

    Copyright:

    © All Rights Reserved
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    HEALTH INSURANCE Chaim Form CARE: Parca cmannrontn CLR? 037022 0511] Section A « Details of Primary Insured PoieyNn : [3°18 Y'913 IC ©) SNorCertiate Nos | | 0 Go 1 AWAD ) Nave KATANT EAN IpPAnoey 0) Ades PUNT IND] lei 3Cik lp nera@ut 2, of? LAXMI NP PAYlAn mo HW DIA, Rank sats ROAD IMAL AD [CA ot oO MUMAAY fue MOAUWAR DN Cpr Al Paco HOOO FP Pronetamoer TAR 1G Gl ty ty Eat VAs oiciane lelpalndey OG mai l> Com Section 8 - Detall of insurance History #) Curerty covered by anyother MedklamMeathinuranve: [| Yer Cfo ©) Date of commencement of fest surance witwua break: [ot] ©) yes Company Name 1 Py Narr i Sumbnne(s) ‘9 Hmeyoumerteentoonlcednveustyersmeneponetiectre! Ye Ma Ome: | + Bens anaes ; Seo See SEE 1) PrevouvcoerestyanycterHedlimMeathhsurwee: |) YH No 1) ye Company Name Section C - Details of Insured Person Hospitalised Tee Me, ynme TARA PAN OEY ya 6 10 B HDuettm 2OO MNES R ]'sooue oud fave ve Maer Sooty) —— (Phe 1) Ccaaputen: [] sence |_| Sat tmpored | Mtiomartar pAses Game as Pbhove Oren (ease Sect) Pa Cote State 1) Prone Number a) rection D - Details of Hospitalisation : 0 Nesctteouwersentes: OT AMO WD ORTHOPAG DLETRIC Hos PEL 5) Poem Catezoy axed : "| On Cae Seale Occupancy Ton Srareg a aac ©) Homtaiaton duet: | ey Y tess Maeroy ©) Oe of rysnyDate Diease fer drecesDae of Devry: [L402 0 27 HN deectaimnen (215)[T18) (Ho? Do DTmectasmison: 04: 0 DDnectDsowge 214) /10]3)Afo 2 by TeofDscurze: 0 J 0 0 1) Miewy pve cane __| Sefinficred Road Traffe Acodent, Substance Abuse/Aicoho! Consumption lela a) a= (a ) Reported to Police: Yes No, =) PRC Report Poke Ramah: | No ) Sen Medone Section E - Detalls of Claim 2) Deisotteresmantexpenecired © Prehorptatontpeses : Rs Ge) Ormertcae) a ©) Memaaiomentrcenies «Re Tous mt () Pomhospatanentxperes: Re (0) Prenospeaenonserot ans (0) Hes Oredeupeont Re (si) Fosshespatntenpenod oon () Ambulance ages a 8) Gamer DomclaryHoronataton (resprovdeceas qarnense) ©) DealsefLump suntan beneftcamed 0 HeptdDaycan Re © Semaicen Bs (©) Creal toes Breit Re () Comalesence Rs 4) CaeDocamertsSstmrted:Chechst (0 CamFormuvssned Go) PrarmacyBi a (0) Conyottnedamnteaton tary (=) Operston ThestreNces (=) Hoxpaa Man bit Zw «es (0) Hoot resus Ye) Decartemauettormagaton . i ee earerenteoe (0) Inwmgnten Reporting CTMALSGHMPE) Le ) saDacarge Summary F(a) DactarsPresergrons a sabi Se a ey Seer a ar ec ee Ea ne vanes et sa eet ESET Re Bet Secon Gonram 1350) teva Weng an crvanoee at . See teeter aie ag ates eee eae aad oleae. Section F - Details of Bills Enclosed Tons pont 8) 2 _Dyloyfoi! Di Hepa an 64 ooro G23 Vos fo), “Pre hapten ie 2s if Py 124) [on “Pos osptalason Bs __Nox hand Porm bi Z ee here ea Ben tamara et Section G = Details of Priiary ank Aedoine pan AUTPR 90200 a ) Account Nanber qd 2) Bark Name & Branch 1D) ChequelD0 parable deals 2) 15 Code Section H= Declaration by the Insured Inert ede wit he foaton isd mts dam fom ste & comet te best my rowed an bee ec ayo i Sever sppreson or cons ye et wih reper oats eaten ots gam ypu tear alba a forfeted Iaisoconsent& authonze TPA Company ta ek racessary mecca norman! docu the person aganst whem ths clam ssc Ihara dace that have mouded al the bls 2 tf Me supolemersary cam except te prefpat nesptalasten cam ay Sane we Dae (2/41 j[0 3)//2] -] Sinature of the Inured pace _ Muna fee caren: eyes) a Cn Utenmrt aorta tn CHM ot -

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