E-Claim Form

Details of Insured Field

Intimation Number:- RAR3112202300006
Policy Number:- 75316079
Member ID:- A5563900
Title:- Mrs
First Name:- ANANYA
Middle Name:-
Last Name:- DAN .
Company TPA/ID number:- A5563900
Phone Number:- 9382597965
Emergency Number:-
Current Diagnosis:- Pregnancy scan and check up
Gender:- FEMALE
Age:- 27
DOB:- 1996-04-20
Relationship with Insured:- Member
Email:- Koushik.pal@hatch.com
Secondary Email:-

Details of Hospitalization
Date of Admission:- 2023-12-19

Details of Claim
Details of the treatment expenses claimed

Hospitalization Expenses:- 2800.00

Details of Lump sum/cash benefit claimed

d) Claim Documents Submitted

Claim Documents Submitted - Checklist:- Yes

Hospital Main Bill:- Yes
Hospital Break-up Bill:- Yes
Hospital Discharge Summary:- No
Hospital Bill Payment Receipt:- No
NEFT /KYCs/ID proof:- No
Investigation Reports (Including
CT/MRI/USG/HPE):- Yes

Copy of the claim intimation, if any:- Yes

Operation Theatre Notes:- No
ECG:- No
Doctor's Prescriptions:- Yes
Others:- No

Details of Primary Insured’s Bank Account

Account Number:- 0541000103107341
Bank Name & Branch:- pnb burdwan branch
IFSC Code:- PUNB0054100
Date:- 2024-01-05

Name / Signature of the Insured:- ANANYA DAN .

By signing this e- claim form, I hereby agree that my electronic signature is the legally binding equivalent
to my handwritten signature. Whenever I execute an e-signature, it has the same validity and meaning as
my handwritten signature and no tampering is made. I will not, at any time in the future, repudiate the
meaning of my electronic signature or claim that my electronic signature is not legally binding