Health Insurance Claim Form printable pdf download

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IMD CODE: 10000006

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 : ______________________________________

Policy End Date _____________________________________

Bajaj Allianz Claimant ID Card No: _______________________________________________________________________________

Corporate Name :

______________________________________________________________________ (Only for Group Policies)

PERSONAL DETAILS OF EMPLOYEE/PROPOSER

Name of the Employee/Individual ____________________________________________________________________________

Employee No (if any) ______________________________________________________________________________________

Date of Joining the Policy (DOJ) ______________________________________________________________________________

E-Mail address of the Employee/Individual ____________________________________________________________________

Contact No (Mobile No) ____________________________________________________________________________________

CLAIMANT / PATIENT DETAILS

Name of the Patient: ______________________________________________________________________________________

Relationship with the Employee / Proposer : Self

/ Spouse

/ Child

/ Parent

/ Others – Please Specify ___________

Date of Birth of Claimant _______________________________ Age : ________________

Gender _______________________

Residential Address _______________________________________________________________________________________

______________________________________________________________________________________________________

CLAIM DETAILS

Total Claimed Amount: Rs.

Claimed Amount in Words: Rupees _____________________________________________________________________________

1. Provisional Diagnosis / Nature of Disease

Enclosure Check List :

_______________________________________________

1. Discharge Summary containing all relevant details.

2. All Bills and their Receipts.

2. Date of Admission : ______________________________

3. All Reports & prescriptions

3. Date of Discharge :_______________________________

5. Certificate regarding Diagnosis

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.

Health Insurance Claim Form