Health Insurance Claim Form

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HEALTH INSURANCE CLAIM FORM
ALL FIELDS IN THIS FORM ARE MANDATORY AND THE CLAIM WILL BE NOT BE PROCESSED IF ANY OF THE
DETAILS ARE MISSING
Claim Number (For BAGIC Use Only)
POLICY DETAILS
Policy No : OG - ___________________________________________________________________________________
Policy Start Date
DD / MM/ YYYY
Policy End Date
DD/MM/YYYY
Bajaj Allianz Claimant ID Card No: ___________________________________________________________________
Corporate Name :
__________________________________________________________ (Only for Group Policies)
PERSONAL DETAILS OF EMPLOYEE/PROPOSER
1
Name of the Employee/Individual
2
Employee No (if any)
DD/MM/YYYY
3
Date of Joining the Policy (DOJ)
4
E-Mail address of the Employee/Individual
5
Contact No (Mobile No)
CLAIMANT / PATIENT DETAILS
1
Name of the Patient:
2
Relationship with the Employee / Proposer
Self / Spouse/ Child / Parent / Others –
Please Specify
3
Date of Birth of Claimant
DD/MM/YYYY
Age : ______
4
Gender
5
Residential Address
CLAIM DETAILS
Total Claimed Amount: Rs.
Claimed Amount in Words: Rupees ____________________________________________________________________
Enclosure Check List :
1.Provisional Diagnosis / Nature of Disease
1. Discharge Summary containing all relevant details.
_____________________________________________
2. All Bills and their Receipts.
3. All Reports & prescriptions
2. Date of Admission :
DD_/_MM_/_YYYY
5. Certificate regarding Diagnosis
3. Date of Discharge :
DD_/_MM_/_YYYY
PLEASE ENCLOSE A PHOTOCOPY OF THE BAJAJ ALLIANZ HEALTH ID CARD
Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required
for each claim

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