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Pe ) I Og:Of) ) G SDKGL LNLD ) Š: Fd'Lxs CF) Ifwf) KRF Aldf BFJL KMF D

This document is an insurance claim form for group medical insurance. It requests information such as the name and details of the insured person, description of illness or injury, treatment details including doctor and hospital information, and bills/receipts. The claimant declares that the information provided is true to their knowledge. The form needs to be submitted to Everest Insurance Company within 30 days of medical treatment.

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bikash Prajapati
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60 views

Pe ) I Og:Of) ) G SDKGL LNLD ) Š: Fd'Lxs CF) Ifwf) KRF Aldf BFJL KMF D

This document is an insurance claim form for group medical insurance. It requests information such as the name and details of the insured person, description of illness or injury, treatment details including doctor and hospital information, and bills/receipts. The claimant declares that the information provided is true to their knowledge. The form needs to be submitted to Everest Insurance Company within 30 days of medical treatment.

Uploaded by

bikash Prajapati
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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k|wfg sfof{noŸ xfQL;f<,, kf]. aS;Ÿ 10675, sf&df)Šf}, g]kfn,


kmf]gŸ 4444717, 4444718, 4445090-92, 4444651, km\ofS;Ÿ 977-1-4444366
O{d]nŸ [email protected], j]jŸ www.everestinsurance.com

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