The New India Assurance Company Limited CLAIM FORM - FOR J P MORGAN MEDICAL INSURANCE POLICY 'ssvance ofthis form does not amount io admission of any lability of under the potcy on the part ofthe insurers Prease give the following information correctly and completely to enable us provass your claim promptly, Name of the Employee: * Ylowerad it Mote clea, Employee Number (JPMC SID)" 4842454 Company Name* Email 0 & Phone Nunbert Mrenckoterha@ yoroil.con Details of the Dependent person" 4, (nrespect of whom claim s made) eT (a) Name & Relationship Bourret \ iotecto (@) Present Completed Age (c) Residential Address Kinnata Aebsurk rel, nv.| Herd t! C19) Hourhe hagas > , ee ws Poficy Number in Ful) :14030034150400000003 se Nature ot Dseaserinesseonacedornuaysusaigy «x46 d ove! ei emratomre, oavonstin musa susanetosece OK Or toss fist dotocted Oo ‘olletise Name and Address of the attending AX 0 Medicai Practitioner Caz ¢ ok @ {b) Quatlication & Telephone No. @ @ Pin Code State /U. Terttory,10, Type of Clim: Hospitalization, 6 PostHosptotzatn: PeS+ Wospihallroslorn (a) Date of Admission” iOS le? Lis= (b) Date of Discharge cal oe{ o> 1. tthe Claim is for Donictiary Hospitalization, Please indicate (2) Date of Commencement of treatment = Not Aaplicable (8) Dato of Compition of treatment ‘Not Applicable (0) Name & Address of attencing Medical” Practitioner Pin Code Stale /U, Terrtory (@) Telephone No.* (@) Registration No. 12. Are you al present covered under any other similar type of scheme Ike P.A, Cancer Insurance, Medictaim (Individual or Group), Heath insurance, elc? If Yes, Piease give particulars of each Not Appjicable (a) Is this tne fist year of coverage under Med ciaim Policy? Yes / Na-Nol Applicable ino, since when have you been continuously insured under Mediciaim Policy, Give detaiis (©) (2) Is this the fist ciaim under this pofcy ? Not Appiicabie (i) fro, please quote Previous claim number and dotais ‘n support of the abave claim, | enclose the [allowing ariginals/ documents: 1. Canceiied cheque" . 2. Age proat ofthe patient? 3. Originai Bis, Cash Paid Receipts and Discharge Summary f card from the Hospita ~ 4. Originat Cash Memas from the Hospitals (s)/ Chomsts(s), supported by proper prescrintions* 5. Original Receipt and Pathological tes! reporis from Pathologist supported by the notefom the atlencing Mecical Practiioner / Surgeon recommending such Pathoiogeal tests* 6. Orginal Surgeon's cortfcate stating nature of operation performed and Surgeons’ bil and receipt” 7. Original Attending Ooclr's! Consultant's! Specials’ / Anesthetist’ bill and receipt, and certfcate rey iagnosis* o 8. Driginal Certficate fom altencing Medical Practioner / Surgeon thatthe patient wsfuly cured. er e os ee ‘Summary of expenses incurred for which origina ils / receipts / cash memas are encod, Total of Hospital Bit Rs = Consultants /Sugeor's “Anesthetst's Fees Rs Diagnostics Tests Rs. Medicines purchase¢ from chemists Rs Z Other expenses not induded above Rs Grand Total Rs.‘rey waran| he nao he foregog paras inevay espe! and agen thal Raveriado or shal make an aa temer my right to claim reimbursement of the Said expenses shall be absolutely tated toc dabare hath teapect te spore resmon ro bonelie we samastle ander any other Medical ‘Scheme or Insurance. J ALSO CONSENT AND AUTHORISE THE THIRD PARTY ADMINISTRATOR TO SEEK MEDICAL INFORMATION FROM ANY HOSPITAL / MEDICAL PRACTITIONER WHD HAS AT ANY TIME ATTENDED ON ME | authotize TPA to recoive payment from insurance company as reimbursement of hospilal bis incurred on my treatment, wtchecebaday ot. O.cfonber..200549 Ow ‘Signature of the Employee Pace: Mb = “Mandatory fleldsrequirements forthe claim reimbursement