Specimen of claim form - Medical insurance - Mediclaim - India, Delhi, Mumbai, Chennai, Kolkata, Pune, India




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SPECIMEN OF A CLAIM FORM TTK HEALTHCARE SERVICES PRIVATE LIMITED

7 Jeevan Bheema Nagar Main Road, HALL IIIrd Stage, Bangalore - 560 075 CLAIM FORM
(Issuance of this Claim Form is not tantamount to acceptance of Liability by the Insurer)

TTK ID No:

Name & Address of the Insured :

(in whose name policy is issued)

Details of Insured Person:

(in respect of whom claim is made)
Name & relationship of the Insured

Present completed Age
Occupation
Contact Address
Phone No.
Mobile No.
E-Mail Address

Name of the Insurance Company ..................................
Policy No........................................... Serial No. Of the Schd/ Certificate No. :

AILMENT / DISEASE / INJURY :

Date of Injury sustained or disease / illness first detected :
Name of the Hospital :

Have you been insured under any mediclaim scheme earlier (held with us or any other insurance co.) If yes,xerox copies of previous years' policies MUST be enclosed.
Date of commencement of very first insurance for this person with continous insurance coverage.

Have you preferred any claim for the same insured under the mediclaim scheme earlier, if so, give the following details :

Previous claim file ref.no/office
Diagnosis
Whether settled/repudiated
Amount (if settled)
Date of Admission

:
:
:
: Rs.
Date of Discharge

TOTAL AMOUNT CLAIMED : Rs.
If the claim is of Domiciliary Hospitalization please indicate

Date of Commencement of the treatment
Date of Completion of treatment
Name & Address of attending Medical Practioner with Telephone No. & Registration No.

Signature of the claimant

I have incurred the below expenses for the treatment of the disease / illness / accident and herewith as per schedule mentioned below: -

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