UNITED INDIA INSURANCE COMPANY LIMTED Divisional Office 010500 No.

.64, Armenian Street, `Catholic Centre, Chennai 600 001 T !" NO" 044 # $5%&'('% ) $5%&'('4 REF:010500/IB GPA/MISC./2012-13 Date: 1 /12 /2012 // !"t#$%t P&e'%(")e // INDIAN BAN* +/++ ,A- MAIN ROAD

OKKUR SIVAGANGAI TAMILNADU -630557

Sirs, Re: GPA POLICY NO.: +2/12/05/000000 CLAIM NO.: +2/12/00001+1

NA* +. +A!,DOSS , CAD- . *ANA. S-.NO." N,!/-ANC0: O**UR D.O.A" 1$.1$.$01$

C,-C! O11,C " MARURAI 2e refer to 3o4r a5ove mentione6 claim an6 7o4l6 re84est 3o4 to sen6 4s the follo7in9 6oc4ments at an earl3 6ate6" I SEE*ING LEA.E SALARY /PAB0 1. nclose6 Claim 1orm 64l3 com:lete6 7ith in 15 Da12 from the 6ate of DISC3ARGE $. nclose6 Me(")a4 Re5$&t 64l3 com:lete6 an6 si9ne6 53 the T&eat"67 P#12")"a6/S%&7e$6 %. Ori9inal Com:4terise6 Salar3 sli: or Atteste6 co:3 of com:4terise6 salar3 sli: for the month of NO; */ - $01$ 4. !eave A::lication of the em:lo3ee an6 sanction letter in official format 7ith 6ate of <oinin9 alon9 7ith /ranch office recommen6ation. 5. *e6ical c4m 1itness Certificate from treatin9 6octor alone onl3 II - IF YOU SEE* MEDICAL REIMBURSMENT FROM US PRODUCE T3E FOLLO!ING ORIGINAL DOCUMENTS. 1. $. %. 4. 5. Doctor=s >rescri:tions, Cash -ecei:ts, >harmac3 /ills,!a5 /ill an6 ?#ra3 /ill @ A4thenticate6 53 treatin9 6octor A Doctor=s fees sho4l6 5e in ori9inal N4m5ere6 cash recei:t is re84ire6. 1irst treatment 6etails at the time of acci6ent ?#ra3 1ilm an6 -e:ort taBen at the time of Acci6ent for o4r >anel Doctor=s verification.

ven if 3o4 6o not 7ant to claim for *e6ical -eim54rsement, :lease 6o sen6 invaria5l3 co:3 of the aforementione6 certificates for o4r recor6s 64l3 atteste6 53 com:etent a4thorit3 7ith seal, Name an6 Desi9nation of the officer attestin9. III ,f 3o4 sen6 ?eroC Co:ies of aA !eave Sanction !etter 5A Salar3 Sli: cA *e6ical c4m 1itness Certificate DA Dischar9e S4mmar3 etc., the same have to 5e com:4lsoril3 atteste6 53 the 5anB official 7ith seal Name an6 Desi9nation of the attestin9 official 7hich :lease note. ThanBin9 3o4, Do4rs faithf4ll3, SR.DI.ISIONAL MANAGER.