MDINDIA HEALTHCARE SERVICES PRIVATE LIMITED

261/2/7, Silver Oak Park, Baner Road, Pune 411045 India

CLAIM FORM
(Insurance of this Claim Form is not tantamount to acceptance of Liability by the Insurer)

Name of the Insurance Company: NIA F NIC F OIC F UNITED F

1) CCN:FFFFFFFFFF 2) MDINDIA No:FFFFFFFFFFFFFFF

3) POLICY NO: FFFFFFFFFFFFFFFFFFFFF

4) POLICY PERIOD:……….…………To………………..
5) NAME OF THE EMPLOYEE/PROPOSER:………………………………………………………………………………………………………………
6) NAME OF THE CLAIMANT:……………….…………………………………………………………..…….…7) OCCUPATION:…………………
8) RELATION:…………………………………………………8) AGE/DOB:…………………………………
9) ADDRESS:………………………………………………………………………………………………………10) CONTACT NO:………………….
11) NATURE OF DISEASE/ILLNESS CONTACTED OR INJURY SUSTAINED:………………………………………………………………………
12) DATE ON WHICH DISEASE/ILLNESS CONTACTED OR INJURY FIRST DETECTED:…………………………………………………………

13) CLAIM FOR HOSPITALISATION F OR DOMICILLIARY HOSPITALISATION F

14) NAME & ADDRESS OF THE ATTENDING MEDICAL PRACTIONER:…………………………………..………………………………………
15) QUALIFICATION & TELEPHONE NO:……………………………….……………………………………………..………………………………
16) REGISTRATION NO OF DOCTOR:……………………………………………………
17) HOSPITAL NAME & ADDRESS:………………………………………………………………………….………………………………………….
18) NUMBER OF BEDS: ………………………….. 19) REGISTRATION NO. OF HOSPITAL:…………………………..……
20) FAMILY PHYSICIAN & CONTACT NO:…………………………………………………..………………..……………………………………….
21) DATE OF ADMISSION:…………….…….….…TIME:………….…..……DATE OF DISCHARGE:……..……………..TIME:……….…………
22) ARE YOU AT PRESENT COVERED UNDER ANY OTHER TYPE OF SCHEME LIKE P.A. CANCER INSURANCE, MEDICLAIM (INDIVIDUAL OR GROUP), HEALTH
INSURANCE ETC. IF YES GIVE THE PARTICULARS OF EACH
A) IS THIS THE FIRST YEAR OF COVERAGE UNDER MEDICLAIM POLICY? YES/NO.
IF NO, SINCE WHEN HAVE YOU BEEN CONTINUOUSLY INSURED UNDER MEDICLAIM POLICY. GIVE
DETAILS……………………………………………………………………..…………………………………………………………….……………
B) 1) IS THIS THE FIRST CLAIM UNDER THIS POLICY? YES/NO.
2) IF NO, PLEASE QUOTE PREVIOUS CLAIM NUMBER & DETAILS……………………………………...………..…………………………..
23) I have incurred the below mentioned expenses for the treatment of the disease I illness I accident and herewith as per schedule mentioned below:

SR.
DATE BILL NO PARTICULARS AMOUNT CLAIMED
NO

GRAND TOTAL

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my
right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other
Medical scheme or insurance.

I ALSO CONSENT AND AUTHORISE MDINDIA HEALTHCARE SERVICES (P) LTD TO SEEK MEDICAL INFORMATION FROM ANY HOSPITAL/ MEDICAL PRACTITIONER
WHO HAS AT ANY TIME ATTENDED ON ME.

I authorize MDIndia to make payment of the claim admissible as per terms, conditions and limitations of the policy to the hospital on my behalf for full and final settlement of hospital
bills.

I also authorize MDIndia to receive payment from insurance company as reimbursement of hospital bills incurred on my treatment.
Dated at………………….this……………….day of……………………………200

Signature of the claimant