Scribd Logo
Upload

Welcome to Scribd!

  • 168 views

    Bajaj Allianz General Insurance Company Limited: Claim Form - Domiciliary and Opd

    Uploaded by

    vkbasava
    The document appears to be a claim form from Bajaj Allianz General Insurance Company for domiciliary and outpatient department (OPD) expenses, which requests details about the patient, treatment received, expenses incurred, and a declaration authorizing Bajaj Allianz to obtain medical information to process the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Bajaj Allianz General Insurance Company Limited: Claim Form - Domiciliary and Opd

    Uploaded by

    vkbasava
    168 views2 pages
    The document appears to be a claim form from Bajaj Allianz General Insurance Company for domiciliary and outpatient department (OPD) expenses, which requests details about the patient, treatment received, expenses incurred, and a declaration authorizing Bajaj Allianz to obtain medical information to process the claim.

    Original Description:

    Informative

    Original Title

    OPD Claim Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document appears to be a claim form from Bajaj Allianz General Insurance Company for domiciliary and outpatient department (OPD) expenses, which requests details about the patient, treatment received, expenses incurred, and a declaration authorizing Bajaj Allianz to obtain medical information to process the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    168 views2 pages

    Bajaj Allianz General Insurance Company Limited: Claim Form - Domiciliary and Opd

    Uploaded by

    vkbasava
    The document appears to be a claim form from Bajaj Allianz General Insurance Company for domiciliary and outpatient department (OPD) expenses, which requests details about the patient, treatment received, expenses incurred, and a declaration authorizing Bajaj Allianz to obtain medical information to process the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Bajaj Allianz General Insurance Company Limited

    CLAIM FORM - DOMICILIARY AND OPD

    Claim no (For BAGIC use Only)

    Policy Details (All Fields are mandatory fields.)

    Policy No : OG-17-1804-8403-00000003
    Policy Start Date : 01-APR-2017 Policy End Date : 31-MAR-2018

    Bajaj Allianz Claimant ID Card No : ______________________________________________________

    Corporate Name : RASHTRIYA ISPAT NIGAM LIMITED (VSP)

    Personal Details of Employee

    1 Name of the Employee:


    2 Name of the Patient :
    3 Age : Gender :
    4 E-Mail address of the Employee :
    5 Contact No (Mobile No) :

    Out Patient Details

    1 Name of the Hospital/Clinic/Consultant :


    2 Address of the Hospital/Clinic/Consultant :

    3 Date of Consultation :
    4 Provisional Diagnosis / Nature of Disease :
    5 Treating Doctors Name :

    Expenses Details
    1 Doctors/Consultants/Specialist’s Fees

    2 Medicines given by Doctor:


    3 Medicines brought from Chemists
    4 Investigations Charges
    5 X –Ray / CT-Scan / MRI/ 2D- Echo
    6 Dental Treatment
    7 Others

    Total
    Notes:
    1. Name/Nature of illness has to be mentioned in the claim form.
    2. All doctor’s Bills/Chemists Bills/Investigation Bills have to be submitted in original.
    3. Copies of all the reports/investigation reports have to be enclosed.
    4. Duly filled NEFT Mandate of Employee with Cancelled Blank Cheque Leaf with Payee Name Printed Or
    Copy of the First page of the Bank Passbook is Mandatory

    DECLARATION:
    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 Bajaj Allianz General Insurance Company Limited, 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.

    Signature of the Authorized Signatory / Employee


    (Name & Designation)

    Company Seal:_____________________

    Date: DD_/_MM_/_YYYY

    PLEASE ENCLOSE A PHOTOCOPY OF THE BAJAJ ALLIANZ HEALTH ID CARD

    You might also like