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UNITED INDIA INSURANCE COMPANY LIMITED Address for Correspondence Medi Assist India TPA Pvt Ltd Green Arch, III Floor, # 45/A, 1st Main Road, Sarakki Indl Layout, 3rd Phase, J.P. Nagar, Bangalore - 5600078 Claim form for Group Mediclaim Insurance Reimbursement Pre or Post Hospitalisation Claim Type OPD Name of the Employee Employee ID E-mail Date of joining Contact Numbers Telephone Mobile Address for sending the cheque if claim is admissible/Failure of EFT Name of the Patient Age in completed years/Date of Birth Date of Birth Age in Years Occupation Relationship and Occupation Nature of Illness/Disease/Accident Date of Injury/Illness/Disease Period of Stay in Hospital (First Date of Illness or disease or accident) Date of Admission Date of Discharge In words

Amount Claimed in Rupees Name of the Bank Bank Branch City/Town where the Bank Branch is located Account No (approved amt for the claim will be directly credited to Emp a/c if details are correct & Claim is admissible) Emp Name ie Accountholder Name as appearing in your Bank statement/Passbook IFSC Code of the Bank Branch

I have incurred on the treatment of disease/illness/accident referred to above, the expenses as per details given by me in the Schedule of Expenses overleaf. In support of the above claim, I enclose the following documents:(to be ticked) 1 2 3 4 5 6 Bills, receipts and Discharge Summary/Certificate/Card from the Hospital. Cash Memos from the Hospital/Chemist(s), supported by the proper prescription. Receipt and pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner Surgeon demanding such pathological tests. Surgeon's certificate stating nature of operation performed and Surgeon's bill and receipt. Attending Doctor's/Consultant's/Specialist's/Anaesthetist's bill, receipt and certificate. Certificate from the attending Medical Practitioner/Surgeon that the patient is fully cured. I further authorise the Company to apply and obtain any Medical Reports or documents or information from the concerned Hospitals / Medical Practitioners who attended on the Insured person. The duly filled and signed claim form along with all the original bills have to be submitted to the HR Department of the respective location. Please Note that any incorrect or incomplete or wrong information given with regard to your Bank details may lead to electronic transfer of money of the Claim proceeds, if admissible, to wrong account or no credit to your account for which you will be solely responsible. Neither the Insurer or Medi Assist India TPA Pvt Ltd will be held responsible for such consequences. I/We agree to indemnify and hold harmless the company Medi Assist India TPA Pvt. Ltd., its Directors, officers and employees against any losses, costs, damages, liabilities, claims and expenses resulting from any wrong information furnished by me/us about our Bank details.

For OPD Claims Consultation Slip, Fee, Investigation Reports etc are required
Date : Place : Name and Signature of the employee

Sl. No

Schedule of Expenses Name of the Hospital, Doctor, Medical Bill No Shop

Bill Date

Amount Claimed

Grand Total