claim form-sample - Life Insurance | Car Insurance ... · with this claim form Total...

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If your company has a TPA, enter the TPA’s ID no. In case you have another health insurance policy As on the health ID card issued to you Type of hospitalization Details If it was a medico legal case. Page 1 Enter your policy number As on policy document Can be you or your family member Your employee code no. Allopathy? Ayurveda? Homeopathy? Etc.

Transcript of claim form-sample - Life Insurance | Car Insurance ... · with this claim form Total...

Page 1: claim form-sample - Life Insurance | Car Insurance ... · with this claim form Total hospitalization bill Signature of the policyholder . To be filled by the hospital in ... claim

If your company has

a TPA, enter the

TPA’s ID no.

In case you

have another

health

insurance

policy

As on the health

ID card issued to

you

Type of

hospitalization

Details

If it was a

medico legal

case.

Page 1

Enter your

policy number

As on policy

document

Can be you or

your family

member

Your employee

code no.

Allopathy?

Ayurveda?

Homeopathy?

Etc.

Page 2: claim form-sample - Life Insurance | Car Insurance ... · with this claim form Total hospitalization bill Signature of the policyholder . To be filled by the hospital in ... claim

In case medical

treatment taken

at home

In case you

have benefit

based plan

Enter all the

bills incurred

before, during

& after

hospitalization

Very

important

payment

details

Page 2

Expenses

incurred before

and after

Hospitalization

List of documents

to be attached

with this claim

form

Total

hospitalization

bill

Signature of the

policyholder

Page 3: claim form-sample - Life Insurance | Car Insurance ... · with this claim form Total hospitalization bill Signature of the policyholder . To be filled by the hospital in ... claim

To be filled

by the

hospital in

concern

Page 3


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