Corporate Name :
Employee Name :
Date :
Employee Id / TPA Id :
Email Id :
KYC details of Insured: Pan Card , Aadhaar Card & NEFT details. (Cancelled Cheque with
printed name)
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIMS YES√ NO×
Duly filled in Claim Form , ECS form , Cancel copy of CHEQUE & photo Id of Patient attested from hospital
Photocopy of TPA card
Whether intimation given to TPA or HR within If not, declaration for delay in intimation
Declaration for delay submission in case claim documents not submitted within time limit
Basic Mandatory document (Part A)
Original copy of consolidated bill on hospitals pre-printed stationery having serial number , detail
break-ups cost wise and quantity wise as break-up of laboratory charges: Disposals Medicines,
Medicines used in OT, Injections, Professional / Consultancy charges, Nursing charges, Details of
Medical care (if any),Details for equipment charges (if any), Room rent – break-up with num
Original copy of the receipt of payment (Bill Payment Receipt with Revenue Stamp) also to attach
receipts for advances if any paid to the hospital, consultants/surgeons within & outside the main
hospital bill.
Original Discharge summary in pre-printed stationery of hospital duly signed by the consultant with
hospital stamp and registration number of the hospital with Name, Age, Gender of the patient &
summary of diagnosis and treatments done
All original prescriptions for the medicine bills attached
All the Original Investigation Reports with Advice / prescriptions letter for Pathological and Medical
investigation with X-ray /MRI films
Xerox copy of hospital registration certificate . If Registration is not there then declaration from hospital
stating no’s of beds in the hospital, 24hrs Nursing staff, Fully Equipped Operation Theater & Qualified Doctors
in the hospital. & Doctor/Surgeon's Registration Number (On Doctor's Letter Head with signature)
Require photo-copy of Indoor case papers.
If hospitalization is for 2 days then declaration from hospital authorities stating time of Admission &
Discharge
First consultation letter for the presenting complaints
For Death Cases along with part A: Death summary in pre-printed stationery of hospital signed by
the consultant with hospital stamp and registration number of the hospital & death certificate from
municipal corporation
For Maternity Cases along with part A: Original copy of treating doctor certificate, & obstetric
history (Gravida, Para, Living children, Abortions) & Last original sonography report
For Accidental Cases along with part A: 1. Attested copy of Medico - Legal Certificate (MLC) report
2. Attested copy of FIR 3. Original copy of treating doctor's certificate with circumstances and injuries
sustained how / when / where (Alcoholic/drugs/intoxicant history before acciden t)
TAX INVOICE PHOTO COPY required for example 1> For IOL in case of Cataract 2> For Stent /
Valve / Pacemaker in case of CABG surgery / Open Heart 3>For Artificial Joints in case of TKR / THR
4> Wire and rods in case accidents Etc..
Self Declaration: This is to confirm that the above mentioned documents have not been submitted by me to
any other insurance company.
Number of pages submitted by the Claimant
(To write page number : Sr.No.01 onwards : for all the pages of your Claim Documen
Employee Receiver
Remarks :
Sign Sign
