REIMBURSEMENT CLAIM FORM TO BE FILLED BY THE INSUREDThe issue of this Form is not to be taken as an admission of liablityDETAILS OF PRIMARY INSURED:a) Policy No.:(To be Filled in block letters)SECTION ASECTION Bb) Sl. No/ Certificate no.c) Company / TPA ID (MA ID)No:e) Address:DETAILS OF INSURANCE HISTORY:a) Currently covered by any other Mediclaim / Health Insurance: b) Date ofcommencement of first Insurance without break:c) If yes, company name: Policy No.Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract?Diagnosis: e) Previously covered by any other Mediclaim /Health insurance : :Date: M MYYYYf) If yes, company name:DETAILS OF INSURED PERSON HOSPITALIZED: DETAILS OF HOSPITALIZATION: DETAILS OF CLAIM:DETAILS OF BILLS ENCLOSED:Sl. No. Bill No. Date Issued by Towards Amount (Rs)SUBMIT CLAIMS DOCUMENT TO BELOW ADDRESSSECTION CSECTION DSECTION ESECTION FSECTION GSECTION HD Y M D Y M 1.2.3.4.5.6.7.8.9.10.D Y M D Y MD Y M D Y MD Y M D Y MD Y M D Y MD Y M D Y MD Y M D Y MD Y M D Y MD Y M D Y MD Y M D Y MCity: State:Pin Code Phone No: Email ID:City: State:Pin Code Phone No: Email ID:D DD DM MM MY YY YYes NoYes NoYes Nod) Name: S U R N A M E F I R S T N A M E M ID D L E N A M Ea) Name: S U R N A M E F I R S T N A M E M I D D L E N A M Eb) Gender Male Female c) Age years M M Y Y Y Y Months d) Date of Birthe) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)(Please Specify) Other Retired Student Home Maker Self Employed Service f) Occupationg) Address (if diffrent from above) :a) Name of Hospital where Admited:b) Room Category occupied: Day careD D M M Y Y H H H H M H M HD D M M Y Y Y YD D M M Y YSingle occupancy Twin sharing 3 or more beds per roomc) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected/Date of Delivery:e) Date ofAdmission: f) Time g) Date of Discharge: h) Time: :No Yes I) If Medicolegalj) System of Medicine:Substance Abuse / Alcohol Consumption I) If injury give cause:Self inflicted Road Traffic Accidentiii. MLC Report & Police FIR attached ii) Reported to Police No Yesa) Details of the Treatment expenses claimedI.Pre -hospitalization expenses iii. Post-hospitalization expensesv.Ambulance Charges:Rs.Rs.Rs.ii.Hospitalization expensesRs.iv.Health-Check up cost:vi. Others (code):Rs.Rs.Rs.Totalvii.Pre -hospitalization period: days viii.Post -hospitalization period: daysb) Claim for Domiciliary Hospitalization: No Yes (If yes, provide details in annexure)c) Details of Lump sum / cash benefit claimed:i. Hospital Daily cash:Rs.Rs.Rs.iii. Critical Illness benefit:v.Pre/Post hospitalization Lump sum benefit:ii. Surgical Cash:iv. Convalescence:vi. Others:Rs.Rs.Rs.Rs. TotalClaim Documents Submitted - Check List:Claim form duly signedCopy of the claim intimation, if anyHospital Main BillHospital Break-up BillHospital Bill Payment ReceiptHospital Discharge SummaryPharmacy BillOperationTheater NotesECGDoctor s request for investigationInvestigation Reports (Including CT/ MRI / USG / HPE)Doctor s PrescriptionsOthersHospital main BillPharmacy BillsPost-hospitalization Bills: NosPre-hospitalization Bills: Nos(IMPORTANT: PLEASE TURN OVER)Medi AssistRDECLARATION BY THE INSURED:Date Y Y D D M M Y Y Place: Signature of the InsuredI hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any materialfact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA / insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.Accenture Services Pvt. Ltd.India Finance Helpdesk (Insurance), Bay 49-M2B, Plant Number 3, Godrej and Boyce complex, L B S Marg, Vikhroli WestMumbai 400079.GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)DATA ELEMENT DESCRIPTION FORMATSECTION A - DETAILS OF PRIMARY INSUREDa)Policy No. Enter the policy number As allotted by the Insurance Companyb)Sl. No/ Certificate No.Enter the social Insurance number or the certificate number ofAs allotted by the oraganizationsocial health insurance schemec)Company TPAID No. Enter the TPA ID No.Licence number as allotted by IRDA and printedin TPA documents.d) Name Enter the full name of the policyholder Surname, First name, Middle nameInclude Street, City and Pin code Enter the full postal address e)AddressSECTION B -DETAILS OF INSURANCE HISTORYa)Currently covered by any other Mediclaim / Health Insurance?Indicate whether currently covered by another Mediclaim /Health InsuranceTick Yes or Nob)Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmatc)Company Name Enter the full name of the Insurance Company Name of the organization in fullPolicy No. Enter the policy number As allotted by the Insurance CompanyIn rupees Enter the total sum insured as per the policy Sum insuredd)Have you been Hospitalized in the last four years since Inception of the contract? Indicate whether hospitalized in the last four years Tick Yes or NoDateEnter the date of Hospitalization Use mm-yy formatDiagnosis Enter the diagnosis detailsOpen TextTick Yes or Noe)Previously covered by any other Mediclaim / HealthInsurance?Indicate whetherpreviously covered by another mediclaim / Health Insurancef)Company Name Enter the full name of the Insurance Company Name of the organization in fullSECTION C -DETAILS OF INSURED PERSON HOSPITALIZEDa) NameEnter the full name of the patient Surname, First name, Middle nameb) Gender Indicate Gender of the patient Tick Male or Femalec) Age Enter age of the patient Number of years and monthsd)Date of BirthEnter Date of Birth of patient Use dd-mm-yy formate)Relationship to primary Insured Indicate relationship ofpatient with policyholder Tick the right option, if others, please specifyf) Occupation indicate occupation of patient Tick the right option. If others, please specify.g)Address Enter the full postal address Include Street, City and Pin codeInclude STD code with telephone numberComplete e-mail addressh)Phone No1)E-mail IDEnter the phone number of patientEnter e-mail address of patientSECTION D - DETAILS OF HOSPITALIZATIONa) Name of Hospital where admited Enter the name of hospital Name of hospital in fullTick the right optionTick the right optionUse dd-mm-yy formatUse dd-mm-yy formatUse hh-mm- formatUse dd-mm-yy formatUse hh-mm- formatTick the right optionTick Yes or NoTick Yes or NoTick Yes or NoOpen Textb) Room category occupiedc) Hospitalization due tod) Date of injury/Date Disease first detected / Date of Deliverye) Date of admissionf) Timeg) Date of dischargeh) TimeI) If injury give cause If Medico legalReported to PoliceMLC Report & Police FIR attachedj) System of Mediceneindicate the room category occupiedindicate reason of hospitalizationEnter the relevant dateEnter date of admissionEnter time of admissionEnter date of dischargeEnter time of dischargeindicate cause of injuryindicate whether injury is medico legalindicate whether police report was filedindicate whether MLC report and Police FIR attachedEnter the system of medicine followed in treating the patientSECTION E - DETAILS OF CLAIMa) Details of Treatment Expencesb) Claim for Domiciliary Hospitalizationc) Details of Lump sum/ Cash benifit claimedd) Claim documents Submitted-Check ListEnter the amount claimed as treatment expencesindicate whether claim is for domiciliary hospitalizationEnter the amount claimed as lump sum / cash benefitindicate which supporting documents are submittedTick Yes or NoTick the right optionIn rupees (Do not enter paise values)In rupees (Do not enter paise values)SECTION F - DETAILS OF BILLS ENCLOSEDIndicate which bills are enclosed with the amount in rupeesSECTION G - DETAILS OF PRIMARY INSUREDs BANK ACCOUNTa) PANb) Account Numberc) Bank Name and Branchc) Cheque/ DD payable detailsc) IFSC CodeEnter the permanent account numberEnter the Bank account numberEnter the Bank name along with the branchEnter the name of the beneficiary the cheque / DD should bemade out toEnter the IFSC code of the Bank branchAs allotted by the Income Tax DepartmentAs allotted by the BankName of the Bank in fullName of the individual / organization in fullIFSC code of the Bank branch in fullSECTION H - DECLARATION BY THE INSUREDRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.