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FGH Claim Form Online

This document contains a health insurance claim form for Future Generali India Insurance. It requests policy and personal details of the employee/proposer and claimant/patient. It also requests claim details including diagnosis, admission/discharge dates, treating doctors' details, and consent to access medical records to process the claim. The claimant must fill all mandatory fields and agrees that false information will forfeit their claim reimbursement.

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Salman Tamboli
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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404 views2 pages

FGH Claim Form Online

This document contains a health insurance claim form for Future Generali India Insurance. It requests policy and personal details of the employee/proposer and claimant/patient. It also requests claim details including diagnosis, admission/discharge dates, treating doctors' details, and consent to access medical records to process the claim. The claimant must fill all mandatory fields and agrees that false information will forfeit their claim reimbursement.

Uploaded by

Salman Tamboli
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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TOLL FREE PHONE: 1800 103 8889 / 1800 209 1016

TOLL FREE FAX: 1800 103 9998 / 1800 209 1017


E MAIL: [email protected]

HEALTH INSURANCE CLAIM FORM - ONLINE


ALL FIELDS IN THIS FORM ARE MANDATORY (Data will be kept confidential)
Claim Number (If Available):

POLICY / INSURED DETAILS

Policy No : _______________________________________________ Health Card No. of Patient ____________________________________________

Policy Start Date _________________ Policy End Date __________________ Date of Joining the Policy __________________________________

Corporate Name : ________________________________________________(Only for Group Policies) Employee ID _________________________

PERSONAL DETAILS OF EMPLOYEE/PROPOSER


1 Name of the Employee / Individual:
2 E-Mail address of the Employee/Individual:
3 Mobile Number :
4 Permanent Account Number (PAN):

CLAIMANT / PATIENT DETAILS


1 Name of the Patient:
2 Relationship with the Employee or Proposer [Self / Spouse / Child / Parent / Others]
3 Date of Birth of Claimant: _______________________ Age _________ Years Gender [Male/Female/Other]

4 Residential Address

CLAIM DETAILS

Total Claimed Amount:

Claimed Amount in Words: Rupees ____________________________________________________________________________________________


1. Diagnosis ________________________________________________________________________________________________________________

2. Admission Date: _______________ __Discharge Date : ___________________________________________________________________________

3. Name of Treating Doctor: ___________________________________________________________________________________________________

4. Mobile No. of Treating Doctor: _______________________________________________________________________________________________

5. Name of Family Physician: __________________________________________________________________________________________________

6. Mobile No. of Family Physician: _____________________________________________________________________________________________

7. Details of other existing Health Policies: _______________________________________________________________________________________

8. Ongoing Medication: ______________________________________________________________________________________________________

CONSENT REQUIREMENT FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT
I hereby authorize Future Generali India Insurance or any agency / individual authorized by them to obtain copies or review in person all my
medical records including but not limited to admission notes, treatment sheets, indoor case papers, investigation reports, prescriptions and
all other documents present in the hospital case file. Details related to my past hospitalisations in your hospital can also be provided /
shown to Future Generali or its authorized representatives. I agree that all information provided above by me in the claim documents is true
and that if I have provided any false or untrue information, my right to claim the reimbursement of expenses shall be absolutely forfeited.

[Claim submitted by]: Name ______________________________________________________


[Claim submitted by] Relationship with Patient: _______________________________________ [No Signature required]
Claim Submission Date: DD_/_MM_/_2020

* During COVID-19 pandemic situation, Future Generali has waived the requirement of signature on the claim form.

Future Generali India Insurance Company Limited


Registered office address : Indiabulls Finance Centre, Tower 3, 6th Floor, Senapati Bapat Marg, Elphinstone (W), Mumbai - 400 013
Corporate Identity No (CIN): U66030MH2006PLC165287 Telephone No 022 4097 6666 and Fax No 22 4097 6900

Email: [email protected] website address www.futuregenerali.in DIP001 – Claim Form


TOLL FREE PHONE: 1800 103 8889 / 1800 209 1016
TOLL FREE FAX: 1800 103 9998 / 1800 209 1017
E MAIL: [email protected]

Future Generali India Insurance Company Limited


Registered office address : Indiabulls Finance Centre, Tower 3, 6th Floor, Senapati Bapat Marg, Elphinstone (W), Mumbai - 400 013
Corporate Identity No (CIN): U66030MH2006PLC165287 Telephone No 022 4097 6666 and Fax No 22 4097 6900

Email: [email protected] website address www.futuregenerali.in DIP001 – Claim Form

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