| 3-Claim Form to be Sent to TPA(Specimen of a Claim Form TTK Health Care Services Private Ltd) |
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| 7 Jeevan Bheema Nagar Main Road,HALL IIIrd Stage,Bangalore-560 075 |
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| Claim Form |
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| (Issuance of this Claim Form is not tantamount to acceptance of Liability by the Insurer) |
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| TTK ID No: |
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| Name & Address of the Insured : |
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| (in whose name policy is issued) |
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| Details of Insured Person: |
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| (in respect of whom claim is made) |
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| Name & relationship of the Insured |
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- Present completed Age
- Occupation
- Contact Address
- Phone No.
- Mobile No.
- E-Mail Address
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Name of the Insurance Company ..................................
Policy No........................................... Serial No. Of the Schd/ Certificate No. :
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| AILMENT / DISEASE / INJURY : |
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Date of Injury sustained or disease / illness first detected :
Name of the Hospital : |
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- 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.
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| Have you preferred any claim for the same insured under the mediclaim scheme earlier, if so, give the following details : |
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- Previous claim file ref.no/office
- Diagnosis
- Whether settled/repudiated
- Amount (if settled)
Date of Admission
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Rs.
Date of Discharge |
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| TOTAL AMOUNT CLAIMED : Rs. |
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| If the claim is of Domiciliary Hospitalization please indicate
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- Date of Commencement of the treatment
- Date of Completion of treatment
- Name & Address of attending Medical Practioner with Telephone No. & Registration No.
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| Signature of the claimant |
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| 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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| Schedule of Expenses incurred by the Claimant |
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FOR TTK ONLY |
| Date |
Bill No. |
Description |
Amount Claimed |
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