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United India Insurance Claim Form

The document is a claim form for an AB Arogyadaan Group Medical Insurance Scheme, which requests information about the policy holder, patient, treating physician, hospital, and itemized bills to process an insurance claim. It notes that submitting the form does not guarantee claim approval and requests bank account details for claim settlement along with a cancelled cheque leaflet to confirm account information.

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Morgan Thomas
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485 views3 pages

United India Insurance Claim Form

The document is a claim form for an AB Arogyadaan Group Medical Insurance Scheme, which requests information about the policy holder, patient, treating physician, hospital, and itemized bills to process an insurance claim. It notes that submitting the form does not guarantee claim approval and requests bank account details for claim settlement along with a cancelled cheque leaflet to confirm account information.

Uploaded by

Morgan Thomas
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

UNITED INDIA INSURANCE COMPANY LIMITED DIVISIONAL OFFICE: IV: 7th Floor, United IndiaTowers, BASHEERBAGH, HYDERABAD- 500

029 CLAIM FORM UNDER AB AROGYADAAN GROUP MEDICAL INSURANCE SCHEME Policy No.050400/48/04/00350 Registered Claim No. GHPL No.____________________________ BA1 No. &Date _______________________ Branch Name & Code __________________ Account No. _________________________

Issuance of this form does not amount to admission of any liability under the claim on the part of the Insurers. Please give the following information correctly and completely to enable the Company to process your claim promptly. 1. 2. Name of the Main A/C Holder Details of the Patient (in respect of whom claim is made) a) Present completed age b) Occupation c) Residential address d) Relation to Policy Holder Nature of the Disease/illness contracted or Injury detected Date of injury sustained or Disease/ illness first detected : : : : : :

3.

4.

: :

5.

a) Name and address of the attending Medical Practitioner b) Qualification & Telephone No : c) Registration No. : a) Name & Address of the Hospital/Nursing Home b) Date of Admission c) Date of Discharge : : :

6.

7.

a) Do you have any other existing Medical Insurance Policy. If so, details : b) Do you have any previous Medical : Insurance Policies. If so, details

Date:

Signature of the Policy Holder

Page No.2

DETAILS OF THE BILLS SUBMITTED (Attach separate sheet if space is not sufficient) [Link]. BILL NO. AMOUNT AMOUNT ALLOWED

TOTAL:

SIGNATURE OF THE POLICY HOLDER For M/s Good Health Plan Ltd : MEDICAL OPINION:

RECOMMENDATION:

BALANCE SUM INSURED AVAILABLE IS RS.

Important Note:1) Please provide us with the Insured persons Bank A/c Details only and not Dependent's Bank Details.

2) Submission of bank account details, is not a guarantee of settlement of the claim.

------------------------------------------------------------------------------------------------------NOTE :- A CHEQUE LEAFLET DULY CANCELLED MAY PLEASE BE ENCLOSED TO HAVE CONFIRMATION OF ABOVE DETAILS. Name of the Main A/C Holder :__________________________________ Name of the Bank Insured Bank A/C No Branch Name Rtgs/Neft IFSC CODE :___________________________________ :___________________________________ :___________________________________ :___________________________________

Account type(saving/current):__________________________________ Bank address Mobile no E-mail ID :__________________________________ :__________________________________ :__________________________________

Date :

Signature of Main A/C Holder

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