To,

Name of the office: Oriental Insurance Co Ltd

Name of the TPA - Medi Assist Insurance TPA Pvt.Ltd

This is to declare that I Mr/Mrs/Ms __________________________________________________ Age

______ Years, Sex ______ is covered under the corporate insurance policy with The Oriental Insurance
Co Ltd., with Employee ID _____________________________

I have submitted / want to submit the claim for myself / my dependent ____________________, but
due to current situation of lockdown (due to COVID 19 restriction) I am unable to send the hard copy of
the required documents. Hence I am sharing the soft copy of those documents in support of the claim,
request you to consider the same & process the claim on submitted documents. Once the restrictions
are lifted & situation gets under control I will be in position to deliver the original documents to you.

I also declare that these documents will not be used for claiming under any other policy and shall submit
the same as and when it is called for or immediately after COVID 19 restriction are eased or lifted
whichever is earlier. If any information & documents found to be misused by me in any manner ; the
recovery of the claim amount, if any, will be borne by me.

I hereby agree and confirm that the personal information contained herein is true and accurate to the
best of my knowledge and in the event of any wrong/inaccurate information provided by me, the
Company may take any action as it may deem fit.

Name
Place
Date
Email ID