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