Claim Form Safeway Tpa Service Pvt.ltd
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1CLAIM FORM
SAFEWAY TPA SERVICE PVT.LTD.
SAFEWAY TPA SERVICE PVT.LTD.
815, Vishwa Sadan, District Centre , Janak Puri, New Delhi
815, Vishwa Sadan, District Centre , Janak Puri, New Delhi
815, Vishwa Sadan, District Centre , Janak Puri, New Delhi – 11 0058
Tel : 011-45451300 Fax :011-41425672/912266466797
41425672/912266466797
Email
Name of the Insurance Company: _____________________________________ Policy No.: ________________________
_____________________________________ Policy No.: ________________________
_____________________________________ Policy No.: ________________________
Safeway Id. Card no.:_________________ Nature of illness____________________________________________
Safeway Id. Card no.:_________________ Nature of illness____________________________________________
Safeway Id. Card no.:_________________ Nature of illness____________________________________________
Name of the Claimant ______________________________________________________________
______________________________________________________________
______________________________________________________________
Address: ___________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Contact No:_________________________________ E
Contact No:_________________________________ E-mail ______________________________________
mail __________________________________________________
Name of the patient: ___________________________Relation with Claimant_______________ Age: ____Sex: M / F ____
Name of the patient: ___________________________Relation with Claimant_______________ Age: ____Sex: M / F ____
Name of the patient: ___________________________Relation with Claimant_______________ Age: ____Sex: M / F ____
Date of injury sustained or Disease first detected: DD/MM/YYYY____________________________________________
Date of injury sustained or Disease first detected: DD/MM/YYYY____________________________________________
Date of injury sustained or Disease first detected: DD/MM/YYYY____________________________________________
Hospital Name and address: _____________________________Regd. No. : ______________ No. of Beds _____________
ess: _____________________________Regd. No. : ______________ No. of Beds _____________
ess: _____________________________Regd. No. : ______________ No. of Beds _____________
Name and Address of attending Doctor:_____________________________________ Regd. No. ___________________
Name and Address of attending Doctor:_____________________________________ Regd. No. ___________________
Name and Address of attending Doctor:_____________________________________ Regd. No. ___________________
Admitted on : Date ______________ Time ________________ Discha
Admitted on : Date ______________ Time ________________ Discharged on: Date _______________ Time ___________
rged on: Date _______________ Time ___________
IPD No. / File No.____________ Room No ________ Type of Room _____________________
IPD No. / File No.____________ Room No ________ Type of Room _____________________
Total Amount Claimed: Rs.______________________________________________________________________________
Total Amount Claimed: Rs.______________________________________________________________________________
Total Amount Claimed: Rs.______________________________________________________________________________
Whether Cashless Facility / claim availed earlier, if yes please provide details:______________________________________
Facility / claim availed earlier, if yes please provide details:______________________________________
Facility / claim availed earlier, if yes please provide details:______________________________________
Previous coverage details, if any:____________________________________________________________________
Previous coverage details, if any:____________________________________________________________________
Previous coverage details, if any:____________________________________________________________________
I HAVE ‘NO OBJECTION’ IN SAFEWAY MEDICLAIM SERV
I HAVE ‘NO OBJECTION’ IN SAFEWAY MEDICLAIM SERVICES PVT LTD. OBTAINING DETAILS OF MY TREATMENT /
ICES PVT LTD. OBTAINING DETAILS OF MY TREATMENT /
COLLECTING DOCUMENTS AND / OR VERIFYING HOSPITAL RECORDS. (THIS MAY BE TREATED AS MY CONSENT FOR
COLLECTING DOCUMENTS AND / OR VERIFYING HOSPITAL RECORDS. (THIS MAY BE TREATED AS MY CONSENT FOR
COLLECTING DOCUMENTS AND / OR VERIFYING HOSPITAL RECORDS. (THIS MAY BE TREATED AS MY CONSENT FOR
1VERIFICATION OF HOSPITAL RECORDS CONCERNING MY ADMISSION)
1VERIFICATION OF HOSPITAL RECORDS CONCERNING MY ADMISSION)
I HEREBY WARRANT THE TRUTH OF THE FOREGOING PARTI
I HEREBY WARRANT THE TRUTH OF THE FOREGOING PARTICULARS IN EVERY RESPECT AND I AGREE THAT IF I HAVE
CULARS IN EVERY RESPECT AND I AGREE THAT IF I HAVE
MADE OR SHALL MAKE ANY FALSE OR UNTRUE STATEMENT, SUPPRESS OR CONCEAL ANY MATERIAL FACT, THEN, MY
MADE OR SHALL MAKE ANY FALSE OR UNTRUE STATEMENT, SUPPRESS OR CONCEAL ANY MATERIAL FACT, THEN, MY
MADE OR SHALL MAKE ANY FALSE OR UNTRUE STATEMENT, SUPPRESS OR CONCEAL ANY MATERIAL FACT, THEN, MY
RIGHT TO CLAIM REIMBURSEMENT OF THE SAID EXPENSES WOULD STAND FORFEITED. I FURTHER DECLARE THAT IN
RIGHT TO CLAIM REIMBURSEMENT OF THE SAID EXPENSES WOULD STAND FORFEITED. I FURTHER DECLARE THAT IN
RIGHT TO CLAIM REIMBURSEMENT OF THE SAID EXPENSES WOULD STAND FORFEITED. I FURTHER DECLARE THAT IN
RESPECT OF THE ABOVE TREATMENT, NO BENEFITS ARE ADMISSIBLE UNDER ANY OTHER MEDICAL SCHEME OR
OF THE ABOVE TREATMENT, NO BENEFITS ARE ADMISSIBLE UNDER ANY OTHER MEDICAL SCHEME OR
OF THE ABOVE TREATMENT, NO BENEFITS ARE ADMISSIBLE UNDER ANY OTHER MEDICAL SCHEME OR
INSURANCE.
Signature (Insured / Claimant)
In support of the above claim, Please enclose the following documents,
In support of the above claim, Please enclose the following documents, in original: -
Copy of ID Card.
Completely filled and signed claim form.
Completely filled and signed claim form.
INSURED’S BANK
INSURED’S BANK DETAIL
Original detailed Discharge Summary
Original detailed Discharge Summary
Final bill of the hospital and the payment receipts in original.
Final bill of the hospital and the payment receipts in original.
BENEFICARY:_________________________________________________
BENEFICARY:_________________________________________________
Package Break-up details, (if applicable)
up details, (if applicable)
All the investigation reports in original.
All the investigation reports in original.
ACCOUNT NO:________________________________________________
ACCOUNT NO:________________________________________________
All the medicine purchase vouchers with supporting prescriptions
se vouchers with supporting prescriptions
IFSC CODE :__________________________________________________
IFSC CODE :__________________________________________________
in original.
Record of treatment taken in Pre & post hospitalization periods, if any.
Record of treatment taken in Pre & post hospitalization periods, if any.
BANK NAME:_________________________________________________
BANK NAME:_________________________________________________
Hospital Registration Certificate with local Government authorities.
Hospital Registration Certificate with local Government authorities.
BANK BRANCH:________________________________________________
BANK BRANCH:________________________________________________
Copy of Authorization Letter
CITY__________________________________________________________
CITY__________________________________________________________
NOTE : DETAIL TO BE FILLED
ED IN RESPECT OF HOLDER/CUSTOMER
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