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8/12/2019 Test Court Order Test by Gp

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HEALTH INSURANCE CLAIM FORM

ALL FIELDS IN THIS FORM ARE MANDATORY AND THE CLAIM WILL BE NOT BE PROCESSED IF ANY OF THE DETAILS ARE MISSING

Claim Number (For BAGIC Use Only) _____________________________________________________________________________

POLICY DETAILS

Policy No : OG - ______________________________________________________________________________________________

Policy Start Date : ______________________________________ Policy End Date _____________________________________

Bajaj Allianz Claimant ID Card No: _______________________________________________________________________________

Corporate Name : ______________________________________________________________________ (Only for Group Policies)

PERSONAL DETAILS OF EMPLOYEE/PROPOSER

1 Name of the Employee/Individual ____________________________________________________________________________

2 Employee No (if any) ______________________________________________________________________________________

3 Date of Joining the Policy (DOJ) ______________________________________________________________________________

4 E-Mail address of the Employee/Individual ____________________________________________________________________

5 Contact No (Mobile No) ____________________________________________________________________________________

CLAIMANT / PATIENT DETAILS

1 Name of the Patient: ______________________________________________________________________________________

2 Relationship with the Employee / Proposer : Self / Spouse / Child / Parent / Others – Please Specify ___________

3 Date of Birth of Claimant _______________________________ Age : ________________

4 Gender _______________________

5 Residential Address _______________________________________________________________________________________

______________________________________________________________________________________________________CLAIM DETAILS

Total Claimed Amount: Rs.

Claimed Amount in Words: Rupees _____________________________________________________________________________

1. Provisional Diagnosis / Nature of Disease

_______________________________________________

2. Date of Admission : ______________________________

3. Date of Discharge :_______________________________

PLEASE ENCLOSE A PHOTOCOPY OF THE BAJAJ ALLIANZ HEALTH ID CARD

Enclosure Check List :

1. Discharge Summary containing all relevant details.

2. All Bills and their Receipts.

3. All Reports & prescriptions

5. Certificate regarding Diagnosis

Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required for each claim.



CONSENT REQUIREMENT FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT

Dear Sir / Madam,

In order to proceed with your claim, Bajaj Allianz General Insurance may need to see your health records. Our doctors may need toreview all your medical records including admission notes, treatment sheets, indoor case papers, investigation reports, prescriptionsand all other documents present in the hospital case file. This will facilitate faster processing and adjudication of your claim. You arerequested to sign the authorization form below to allow Bajaj Allianz General Insurance access to the above medical records.

AUTHORIZATION FORM FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT

Medical Director

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Dear Sir / Madam,

I _______________________________________________________________ (Name of Patient) was admitted in your hospital from

__________________________ to ___________________________. I am insured with Bajaj Allianz General Insurance as per the policy

details given overleaf.

I hereby authorize Bajaj Allianz General Insurance or any agency / individual authorized by them to obtain copies or review in person allmy medical records including but not limited to admission notes, treatment sheets, indoor case papers, investigation reports, prescriptionsand all other documents present in the hospital case file. Details related to my past hospitalisations in your hospital can also be provided/ shown to Bajaj Allianz or its authorized representatives.

Verification of the above consent can be obtained from me at _____________________________________ (Patient / Relative PhoneNumber)

Name of Patient / Relative: ______________________________________________________

Relationship with Patient: _______________________________________________________

Signature of Patient / Relative: ___________________________________________________

Date: _______________________________________________________________________



Payment of Claims/ Refunds Through National Electronic Funds Transfer Service (NEFT)

RBI has introduced a new system of electronic transfers, National Electronic Funds Transfer (NEFT) and we are now pleased to inform you that we are offering the NEFT facility to our esteemed customers so as to enable you to receive your claims/ refunds throughelectronic mode to your bank account.

The National Electronic Funds Transfer (NEFT) has been introduced from 1st June, 2006. This new system requires the Indian FinancialSystems Code (IFSC) for NEFT of your bank branch along with other details. The NEFT facility also provides adequate protection against

fraudulent interception and encashment of cheques apart from eliminating loss/damage of cheques in transit. The NEFT facility furthereliminates unwarranted correspondence for revalidation/issuance of duplicate cheques.

Under the NEFT facility, your bank will credit the claim/ refund amount in your account after approval and indicate the credit entry as"NEFT" in your Pass Book/Bank Statement without issuing or handling paper instruments/ cheques. This facility is free to the recipient.

In order to avail the NEFT facility, you are requested to fill and sign the enclosed NEFT mandate form. The completed form thereafter canbe sent to us alongwith the claim documents. All information should be accurate and complete so that you get the credit of claim /refund in time. Kindly attach a photocopy of a cheque from your cheque book issued by your bank. Please check whether NEFT issupported by your bankers at your location and also ensure that your Bank Official countersign the mandate form., to ensure that thefunds transfer will not be returned in any case and funds are credited immediately,

Please note that these instructions from you will supersede all your previous mandates & details.



NATIONAL ELECTRONIC FUNDS TRANSFER SERVICE MANDATE FORM

ToBajaj Allianz General Insurance Company Ltd.

Office :Office Address:

Dear Sir, Form for National Electronic Funds Transfer Services for Credit of Claim/ Refund

Please fill in the information in CAPITAL LETTERS. Please TICK wherever is applicable.

1. Partner ID :- (To be filled in by Office - only for Office Use)

2. Full Name (as appears in your bank account):

Shri / Smt. / Kum. / M/s. ___________________________________________________________________________________

3. Bajaj Allianz Health Card No. of Employee (MANDATORY) ________________________________________________________

4. Full Address : ____________________________________________________________________________________________

______________________________________________________________________________________________________

Pin Code ___________________________ Contact/Mobile No ____________________________________________________

4. Email ID________________________________________________________________________________________________

5. Particulars of bank:

Bank Name _____________________________________________________________________________________________

Branch Name & Address ___________________________________________________________________________________

______________________________________________________________________________________________________

Branch Telephone No & Contact No _________________________________________________________________________

Branch MICR Code _______________________________________________________________________________________

Branch IFSC Code for NEFT _________________________________________________________________________________

( Please attach a Xerox copy of a cheque or a blank cheque of your bank duly cancelled for ensuring accuracy of the bank name,branch name and account number)

Account Type Savings Current Cash Credit

Account No. (as appearing in the cheque book) ________________________________________________________________

6. Date from which the mandate should be effective: _______________________ (Please indicate 1st of the month from which youwish to avail this facility. The mandate will be effective from the payment cycle which falls due in the next month)

I hereby declare that the particulars given above are correct and complete. If any transaction is delayed or not effected at all for reasonsof incomplete or incorrect information, I shall not hold Bajaj Allianz General Insurance Company Ltd. responsible. I also undertake toadvise any change in the particulars of my account to facilitate updation of records for purpose of credit of claim / refund amountthrough NEFT.

PLACE: _______________________ ______________________________________

(Beneficiary's Signature)DATE: ________________________

Certified that the particulars of Bank Account as well as IFSC code for NEFT furnished above are correct as per our records and funds canbe transferred to this account using NEFT.

Place: _________________________

Date: _________________________ _____________________________________________

(Signature & Seal of the Manager of the Bank Concerned

BJAZ/HEALTH CF / 01 / 2010

test court order test by gp

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