If your company has

a TPA, enter the

TPA’s ID no.

In case you

have another

health

insurance

policy

As on the health

ID card issued to

you

Type of

hospitalization

Details

If it was a

medico legal

case.

Page 1

Enter your

policy number

As on policy

document

Can be you or

your family

member

Your employee

code no.

Allopathy?

Ayurveda?

Homeopathy?

Etc.

In case medical

treatment taken

at home

In case you

have benefit

based plan

Enter all the

bills incurred

before, during

& after

hospitalization

Very

important

payment

details

Page 2

Expenses

incurred before

and after

Hospitalization

List of documents

to be attached

with this claim

form

Total

hospitalization

bill

Signature of the

policyholder

To be filled

by the

hospital in

concern

Page 3