PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No.

006)
[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]
Plot no.A-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code – 400 604
CLAIM ACKNOWLEDGMENT SHEET
Name of Insurer : PHS ID :
Insured Name : Employee No :
Patient Name : Mobile No :
Policy No : Phone (STD) :
Name of Corporate:
Type of Claim (To Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash Benefit E-Mail ID of
be ticked) : primary insured :
CLAIM DOCUMENT CHECK LIST
Document
Sr. No Description Remarks
Status(Y/N)
IRDA Claim Form duly signed by the Insured & Hospital
Part-A: Duly signed by the insured with Claimed amount ,Mobile number & Email ID along with PHS ID
1 Part-B: Duly signed and stamped by hospital
Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals.

In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating
2 reason for the same.
Original Cancelled Cheque Leaf of Employee/Proposer with the Name of the Account Holder Printed on the Cheque
3 Leaf.
ID Proof of Employee / Primary Insured- Any of one (Passport,Voter ID, Driving License, Or any Government Approved
4
ID ) . If Claim is above 1 lakh- PAN is mandatory with address Proof
5 ID Proof of Patient- Any of one (Passport,Voter ID, Driving License, Or any Government Approved ID )
Original detailed Discharge Summary as per IRDA Format / Day care summary from the hospital (in case of Day Care
6 Treatment) / Death Summary (in Case of Death Claim)

6.a Copy of the Legal heir certificate (if the claim is for the death of the principle insured)

6.b Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)
7 Policy Copy ( if individual policy)
8 64VB Compliance Certificate ( If individual policy)
9 Original Final Hospital bill with cost wise breakup of each Item
10 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)
Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment Slip
10.a as received from the Vendor
Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/ Mesh/ IOL
11

12 Original bills, original Payment Receipts and investigation / Laboratory Reports

Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.
13

14 Original copy of First Consultation letter and subsequent Prescriptions.

Hospital Registration certificate issued by Competent authority as per Indian nursing council Act 1947 (If hospital not
15
falls in GIPSA/PPN )
16 OTHER DOCUMENTS
Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)
16.a

16.b Original Sonography Report in case of Maternity Claim

Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract
16.c
Claim
Copy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in case
16.d of Road Traffic Accident (RTA)
A medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along with
16.e the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness Cases)

In case of claims where the insured has submitted documents to another insurance co./TPA, he needs to submit
16.f attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills
and receipt for the same in originals.
Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hospital
Claim Submitted by: Mobile No.
Date of Claim PHS Executive
DD/MM/YYYY HH:MM
Submission: Name:
Claim Submitted at: PHS - (Location) / Help Desk Signature:
Important Points to Remember:-
1. Please mark either √ or × against respective check box
2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk
3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital
4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt of
your claim documents by us
5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App
6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved & agreed
by Insurer
7. Corrections in any documents are not allowed, otherwise it will not be entertained during adjudication.
 Max Life Insurance Company Ltd.
90 A, Sector-18, Udyog Vihar, Gurgaon-122015, Haryana,
Phone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577
Email- [email protected]

CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT FOR

MEDICASH, MEDICASH PLUS AND HEALTHY FAMILY FLOATER
CLAIM FORM ± PART A
To be filled in by the Insured
The issue of this form is not to be taken as an admission of liability
(To be filled in block letters)

SECTION A ± DETAILS OF PRIMARY INSURED

a) Policy No.: b) Sl. No/ Certificate No.:
c) Company/ TPA ID No.:

d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
e) Address:

City: State:
Pin Code: Phone No.: Email ID:

SECTION B- DETAILS OF INSURANCE HISTORY

a) Currently covered by any other Mediclaim health insurance: Yes No b) Date of commencement of first insurance without break: D D M M Y Y Y Y
d) Policy
c) If Yes, Company Name: No.:

e) Sum Insured (Rs): f) Have you been hospitalized in the last four years since inception of the contract : Yes No Date: M M Y Y

Diagnosis: g) Previously covered by any other Mediclaim/Health insurance: Yes No

h) If Yes, Company Name:

SECTION C- DETAILS OF INSURED PERSON HOSPITALISED

a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
b) Gender: Male Female c) Age: Y Y M M d) Date of Birth: D D M M Y Y Y Y
e) Relationship to
primary Insured: Self Spouse Child Father Mother Other Please Specify:
f) Occupation: Service Self employed Homemaker Student Retired Other Please Specify:
g) Address (if different
from above)

City: State:
Pin Code: Phone No.: Email ID:

SECTION D- DETAILS OF HOSPITALIZATION

a) Name of the Hospital where admitted:

b) Room Category occupied: Daycare Single Occupancy Twin Sharing 3 or more beds per room
c) Hospitalization due to: Illness Injury Maternity d) Date of Injury/ Date of disease first detected/ Date of delivery: D D M M Y YY Y

e) Date of admission: D D M M Y Y Y Y f) Time: H H : M M g) Date of discharge: D D M M Y Y Y Y h) Time: H H :M M

I) If injury, give cause: Self Inflicted Road Traffic Accident Substance Abuse Alcohol Consumption

ii) If Medico legal: Yes No ii) Reported to police?: Yes No iii) MLC Report, & Police FIR attached? Yes No

j) System of medicine:

SECTION E- DETAILS OF CLAIM

a) Details of the treatment expenses claimed Claim Documents Submitted- Check List:

ii) Pre-Hospitalization Expenses Rs. ii) Hospitalization Expenses Rs. Duly filled and signed Claim Form

iii) Post-Hospitalization Expenses Rs. iv) Health-Check up Cost Rs. Copy of intimation letter, if any

v) Ambulance Charges Rs. vi) Others (code) Rs. Hospital Main Bill
Hospital Break Up bill
Total Rs.
Hospital Bill Payment Receipt
vii) Pre-Hospitalization Period Days viii) Post -Hospitalization Period Days
Hospital Discharge Summary
b) Claim for Domiciliary Hospitalization: Yes No (if yes, please provide details in annexure) Pharmacy Bill
Operation Theater Notes
c) Details of Lumpsum/ cash benefit claimed:
ECG
ii) Hospital Daily Cash Rs. ii) Surgical Cash Rs.
Doctor's Request for Investigation
iii) Critical Illness Benefit Rs. iv) Convalescence Rs.
Doctor's Prescription
v) Pre/Post hospitalization Rs. vi) Others Rs. Investigation Reports ( Including
Lump sum benefit CT, MRI/USG/HPE)
Total Rs. Others

SECTION ± F DETAILS OF BILLS ENCLOSED

Sr. No. Bill No. Date Issued By Towards Amount (Rs)

1. D D M M Y Y Hospital main bill
2. D D M M Y Y Pre - hospitalization bills - Nos.
3. D D M M Y Y Post - hospitalization bills - Nos.
4. D D M M Y Y Pharmacy bills
5. D D M M Y Y
6. D D M M Y Y
7. D D M M Y Y
8. D D M M Y Y
9. D D M M Y Y
10. D D M M Y Y

Max Life Insurance/ Ver. 1.5, Nov¶

 Max Life Insurance Company Ltd.
90 A, Sector-18, Udyog Vihar, Gurgaon-122015, Haryana,
Phone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577
Email- [email protected]
SECTION ± G DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN: b) Account Number:

c) Bank Name/ Branch:

d) Payable details: Cheque/ DD: e) IFSC Code:

SECTION H ± DECLARATION BY THE INSURED

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent &
authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against
whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except
the pre/post-hospitalization claim, if any.

Date: D D M M Y Y Y Y Place: Signature of Insured:

GUIDANCE FOR FILLING CLAIM FORM ± PART A (To be filled in by the insured)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
b) SI. No/ Certificate No. Enter the social insurance number or the certificate As allotted by the organization
number of social health insurance scheme
c) Company TPA ID No. Enter the TPA ID No. License number as allotted by IRDA and printed
in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Indicate whether currently covered by another Tick Yes or No
Health Insurance? Mediclaim / Health Insurance
b) Date of Commencement of first Insurance Enter the date of commencement of first insurance Use dd-mm-yy format
without break
c) Company Name Enter the full name of the insurance company Name of the organization in full
Policy No. Enter the policy number As allotted by the insurance company
Sum Insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last four years Indicate whether hospitalized in the last 4 years Tick Yes or No
since inception of the contract?
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim/ Health Indicate whether previously covered by another Tick Yes or No
Insurance? Mediclaim / Health Insurance
f) Company Name Enter the full name of the insurance company Name of the organization in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please
f) Occupation Indicate occupation of patient Tick the right option. If others, please
g) Address Enter the full postal address Include Street, City and Pin Code
h) Phone No Enter the phone number of patient Include STD code with telephone number
I) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease first detected/ Date of Enter the relevant date Use dd-mm-yy format
Delivery

Insurance is the subject matter of solicitation

e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
I) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
SECTION E ± DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
d) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees

SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN Enter the permanent account number As allotted by the Income Tax department
b) Account Number Enter the bank account number As allotted by the bank
c) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full
d) Cheque/ DD payable details Enter the name of the beneficiary the cheque/ DD Name of the individual/ organization in full
should be made out to
e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

Max Life Insurance/ Ver. 1.5 Nov¶

 Max Life Insurance Company Ltd.
90 A, Sector-18, Udyog Vihar, Gurgaon-122015, Haryana
Phone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577
Email- [email protected]

CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT

FOR MEDICASH, MEDICASH PLUS AND HEALTHY FAMILY FLOATER
CLAIM FORM ± PART B
TO BE FILLED IN BY THE HOSPITAL

DETAILS OF HOSPITAL
a) Name of Hospital

b) Hospital ID c) Type of Hospital Network Non-Network If non-network fill section E

d) Name of the treating doctor S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Qualification f) Registration No. with State Code

g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient S U R N A M E F I R S T N A M E M I D D L E N A M E

Registration No. c) Gender Male Female d) Age Years Y Y Months M M e) Date of Birth D D M M Y Y

f) Date of Admission: D D M M Y Y 9) Time: H H :M M h) Date of Discharge D D M M Y Y i) Time: H H : M M

j) Type of Admission Emergency Planned Day Care k) If maternity i. Date of Delivery D D M M Y Y ii) Gravida Status

l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i) Primary Diagnosis i. Procedure 1.

ii) Additional Diagnosis ii. Procedure 2.

iii) Co-morbities: iii. Procedure 3.

iv) Co-morbities iv). Procedure 4.

c) Present ailment is a complication of PED? YES NO If Yes, specify details

d) Pre-authorization obtained: YES NO e) Pre-authorization Number

f) If authorization by network hospital not obtained, give reason:

g) Hospitalization due to injury: Yes No i. If Yes, give cause Self-inflicted? Road Traffic Accident Substance Abuse/Alcohol Consumption

ii. If Injury due to Substance abuse/ Alcohol Consumption, Test Conducted to establish this: Yes No (If yes, attach reports)

iii. If Medico Legal: Yes No iv) Reported to Police : Yes No v) FIR No.

vi) If not reported to Police give reasons

CLAIM DOCUMENTS SUBMITTED. CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorized request CT/MRI/USG/HPE investigation reports

Copy of the Pre-authorization approval letter 'RFWRU·VUHIHUHQFHVOLSIRULQYHVWLJDWLRQ

Copy of photo ID card of patient verified by hospital ECG

Hospital Discharge summary Pharmacy bills

Operation theatre notes MLC report & Police FIR

Hospital main bill Original death summary from hospital where applicable

Hospital break-up bill Any other, please specify

DETAILS IN CASE OF NON-NETWORK (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of Hospital:

City: State:

Max Life Insurance/ Ver. 1.5 Nov¶

 Max Life Insurance Company Ltd.
90 A, Sector-18, Udyog Vihar, Gurgaon-122015, Haryana
Phone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577
Email- [email protected]

Pin Code: b) Phone No. c) Registration No.

d) PAN e) Number of Inpatient beds f) facilities available in the hospital: i. OT: Yes No :

ii) ICU: Yes No iii). Others

DECLARATION BY THE INSURED (PLEASE READ VERY CAREFULLY)

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material
fact, my right to claim reimbursement shall be forfeited.I also consent & authorize TPA I insurance company, to seek necessary medical information I documents from any hospital/Medical Practitioner who has
attended on the person against whom this claim is made.I hereby declare that I have included all the bills I receipts for the purpose of this claim & that I will not be making any supplementary claim except the
pre/post hospitalization claim, if any.

Date: D D M M Y Y Place: Signature of Insured:

DECLARATION BY THE HOSPITAL

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false
or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited. The signature of the insured is
taken on this form after Claim Form B is fully filled up by us.

Date: : D D M M Y Y Signature and seal of hospital authority

Place:

CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

In-patient Treatment /Day Care Procedures

Duly filled and signed Claim Form.
Photocopy of ID card / Photocopy of current year policy.
Original Detailed Discharge Summary with date of admission & discharge, clinical history, past history / procedure details/ Day care summary
from the hospital.
Original consolidated hospital bill with break up of each Item, duly signed by the insured.
Original payment Receipt of the hospital bill.
First Consultation letter and subsequent Prescriptions.
Original bills, original payment receipts and Reports for investigation.
Original medicine bills and receipts with corresponding Prescriptions.
Original invoice/Sticker of implants/bills for Implants (viz. Stent /PHS Mesh/ IOL etc.) with original payment receipts
Road Traffic Accident
In addition to the In-patient Treatment documents:
Copy of the First Information Report from Police Department / Copy of the Medico-Legal Certificate.
In Non Medico legal cases
Treating Doctor's Certificate giving details of injuries (How, when and where injury sustained)
In Accidental Death cases
Copy of Post Mortem Report & Death Certificate (If conducted)
For Death Cases
In addition to the In-patient Treatment documents:
Original Death Summary from the hospital.
Copy of the Death certificate from treating doctor or the hospital authority.
Copy of the Legal heir certificate, if the claim is for the death of the principle insured.

Pre and Post-Hospitalization expenses

Duly filled and signed Claim Form.
Photocopy of ID card / Photocopy of current year policy.
Original Medicine bills, original payment receipt with prescriptions.
Original Investigations bills, original payment receipt with prescriptions and report.
Original Consultation bills, original payment receipt with prescription.
Copy of the Discharge Summary of the main claim.

Organ Donation/Transplantation
In addition to the documents of general hospitalization
Organ Function test / blood test proving organ failure.
Treatment Certificate issued by the Transplant Surgeon of the hospital concerned.

Ambulance Benefit
Duly filled and signed Claim Form.
Photocopy of ID card / Photocopy of current year policy.
Original Bill with Original Payment Receipt.
Treating Doctor's consultation prescription indicating Emergency Hospitalization

Max Life Insurance, Ver.1.5 NRY¶

 Max Life Insurance Company Ltd.
90 A, Sector-18, Udyog Vihar, Gurgaon-122015, Haryana
Phone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577
Email- [email protected]

GUIDANCE FOR FILLING CLAIM FORM ± PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF HOSPITAL

a) Name of Hospital Enter the name of hospital Name of hospital in full

b) Hospital ID Enter ID number of hospital As allocated by the TPA

c) Type of Hospital Indicate whether In network or non network hospital Tick the right option

d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
Enter the registration number of the doctor along
f) Registration No. with State Code with the state code As allocated by the Medical Council of India

g) Phone No. Enter the phone number of doctor Include STD code with telephone number

SECTION B ± DETAILS OF THE PATIENT ADMITTED

a) Name of Patient Enter the name of hospital Name of hospital in full

b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider

c) Gender Indicate Gender of the patient Tick Male or Female

d) Age Enter age of the patient Number of years and months

e) Date of Admission Enter date of admission Use dd-mm-yy format

f) Time Enter time of admission Use hh:mm format

g) Date of Discharge Enter date of discharge Use dd-mm-yy format

h) Time Enter time of discharge Use hh:mm format

i) Type of Admission Indicate type of admission of patient Tick the right option
j) If Maternity

Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format

Gravida Status Enter Gravida status if maternity Use standard format

k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SECTION C ± DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code
Enter the ICD 10 Code and description of the
Primary Diagnosis primary diagnosis Standard Format and Open text
Enter the ICD 10 Code and description of the
Additional Diagnosis additional diagnosis Standard Format and Open text

Enter the ICD 10 Code and description of the co-

Co-morbidities morbidities Standard Format and Open text

b) ICD 10 PCS

Enter the ICD 10 PCS and description of the first

Procedure 1 procedure Standard Format and Open text

Enter the ICD 10 PCS and description of the

Procedure 2 second procedure Standard Format and Open text
Enter the ICD 10 PCS and description of the third
Procedure 3 procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
Indicate whether present ailment is a complication
c) Present Ailment is a Complication of PED of some pre- existing disease Tick Yes or No

d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No

e) Pre-authorization Number Enter pre-authorization number As allotted by TPA

Enter reason for not obtaining pre-authorization
f) If authorization by network hospital not obtained, give reason number Open text

g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No

Cause Indicate cause of injury Tick the right option

If injury due to substance abuse/alcohol consumption, test conducted to establish
this Indicate whether test conducted Tick Yes or No

Medico Legal Indicate whether injury is medico legal Tick Yes or No

Reported To Police Indicate whether police report was filed Tick Yes or No

FIR No. Enter first information report number As issued by police authorities

If not reported to police, give reason Enter reason for not reporting to police Open Text
SECTION D ± CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E ± DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address Include Street, City and Pin Code

b) Phone No. Enter the phone number of hospital Include STD code with telephone number

c) Registration No. Enter the registration number of patient As allocated by the Hospital

d) PAN Enter the permanent account number As allotted by the Income Tax department

e) Number of Inpatient Beds Enter the number of inpatient beds Digits

f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDA)

Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used (Any one of the mentioned documents) Passport/ PAN Card/ Voter's Identity Card/ Driving License/ Letter from a
recognized public authority or public servant verifying the identity and residence
of the customer
Proof of Residence (Any one of the mentioned documents) Telephone bill/ Bank account statement/ Letter from any recognized public
authority/ Electricity bill/ Ration card
Please send the documents to any Max Life Branch Office or send the documents to below address.
PARAMOUNT HEALTH SERVICES (TPA) PVT. LTD,
R.O.: D-39, Okhla Industrial Area Phase-I, Near D.D Motors, New Delhi-110020.
For any assistance Call - PHS Toll free - 1800-290-3151. Tel. No.: 011-41637594/95/96. Fax: 011-41637592, 011-42890927/921.
E-Mail: [email protected]

Max Life Insurance, Ver. 1.5,Nov¶