NATIONAL INSURANCE COMPANY LIMITED Address of Policy Issuing Office

Administered by Medi Assist India TPA Private Limited Bangalore Divisional Office III
Regd Office : " Shilpa Vidya", 3rd Floor, 15-17-19, Shri Lakshmi Complex,
# 49, 1st Main Road, Sarakki Indl Layout, J P Nagar 3rd Phase, St Mark's Road, Bangalore 560 001
Bangalore 560 078 Tel No : 558 7443 Fax : 558 6336
Claim form for Infosys Group Mediclaim Insurance E mail : nicdo3.bangalore@vsnl.com

1 Name of the Infoscion

2 Employee ID E-mail
3 Date of Joining
3 Contact Numbers Mobile Number
4 Name of the Patient
5 Age in completed years/Date of Birth of Patient Date of Birth Age in Years
6 Patient Relationship with the employee Occupation
7 Nature of Illness/disease/accident

8 Date of Injury/Illness/Disease (First Date of Illness or disease or accident)

9 Period of Stay in Hospital Date of Admission

Date of Discharge

10 ICICI Bank Account No (Pls note the approved amt Bank Name ICICI Bank Name of Bank Branch
for the claim will be directly credited to you’re a/c)
IFSC Code of ICICI Bank Branch
Bank Account Number
Name of the Account Holder
Please Note that any incorrect or incomplete or wrong information given with regard to your Bank details may lead to electronic
transfer of money of the Claim proceeds, if admissible, to wrong account or no credit to your account for which you will be solely
responsible. Neither the Insurer or Medi Assist India TPA Pvt Ltd will be held responsible for such consequences.
I/We agree to indemnify and hold harmless the company Medi Assist India TPA Pvt. Ltd., its Directors, officers and employees
against any losses, costs, damages, liabilities, claims and expenses resulting from any wrong information furnished by me/us about
our Bank details.
11 Amount Claimed in Rupees

I have incurred on the treatment of disease/illness/accident referred to above, the expenses as per details given by
me in the Schedule of Expenses overleaf. In support of the above claim, I enclose the following documents:(to be ticked)
1 Hospital Bills, receipts and Discharge Summary/Certificate/Card from the Hospital. (All Original)
2 Cash Memos from the Hospital/Chemist(s), supported by the proper prescription. (Original)
3 Receipt and pathological test reports from a Pathologist supported by the note from the attending
Medical Practitioner Surgeon demanding such pathological tests. (Original)
4 Surgeon's certificate stating nature of operation performed and Surgeon's bill and receipt. (Original)
5 Attending Doctor's/Consultant's/Specialist's/Anaesthetist's bill, receipt and certificate. (Original)
6 Certificate from the attending Medical Practitioner/Surgeon that the patient is fully cured.

I further authorise the Company to apply and obtain any Medical Reports or documents or information from
the concerned Hospitals / Medical Practitioners who attended on the Insured person.

The duly filled and signed claim form along with all the original bills have to be submitted to the Finance & Accounts
of the respective location.

No of Documents

Date and Place : Signature of the Infoscion

For Office Use only

Policy Number : Claim settled for Rs

Claim Number : Date of settlement
 Schedule of Expenses
Sl. Name of the Hospital, Doctor, Medical Amount
Bill No Bill Date
No Shop Claimed

Grand Total
File : INFOSYS_CLAIM_FORM 7799 Run Date : 8/26/2019