Bajaj Allianz General Insurance Co. Ltd.

Bajaj Allianz House, Airport Road, Yerwada, Pune-411006. Reg.: 113 I CIN: U66010PN2000PLC015329
For more details, log on to: www.bajajallianz.com
Email id:[email protected]
Toll free no:1800-209-5858
020-30305858 (To be filled in block letters)

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A
TO BE FILLED IN BY THE INSURED
The issue of this form is not to be taken as an admission of liability
DETAILS OF PRIMARY INSURED
a) PolicyNo: I OI G I - I 2 I 4 I - I 9 I 9 I 0 I 6 I - 8 I 4 I 0 I 3 I - I 0 0 0 0 0 1 I 6 I 9 I b) SI.No/CertificateNo:�I ����
c) CompanyTPA IDNo: I I I I I I I I I I I I I d) Customer ID:�I �I �I �I _I���
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e) CompanyName:___________________f)EmployeeNo:_________
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g)Name: I I I I I I I I I I m

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h) Address:
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City: I I I I State:�I _.__.,_____,___,____,__-'--,_I _._I---'-I _.IPin Code: ����

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PhoneNo: I I I Email ID:___________________
DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Insurance LJ Yes ✔ No
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b) date of commencement of first insurance without break LJLJ LJLJ I I I I
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c) If yes, company name: I I I I I I I I I I I I I I I I PolicyNo: I I I I I I I I I I I I I I I en
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Sum Insured(Rs.): I
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d) Have you been hospitalized in the last four years since inception of the contract? lJYes lJNo
✔ Date: l..Q1QJ �I I YI YI YI YI z
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Diagnosis�-------------------�
e) Previously covered by any other Mediclaim / Health Insurance: LJ Yes LJ
✔ No

f) If yes, CompanyName I I I I I I I I I I I I I I I I I

DETAILS OF INSURED PERSON HOSPITALIZED

a)Name of the Patient:___________________
SHAIKH ARFA TABREZ ALAM ____________
b) Health ID card no of the Patient:._________
GMC-24990630169-INN070A ___________________
c) Gender: MalelJFemalelJ
✔ d) Age:years 3 0 months 0 8 LJLJ LJLJ e) Date ofBirth l_QJ_QJ
2 2 0 2 �I I Y1 I Y9 I 9YI Y4 I en
f) Relationship of Primary insured:Self LJ Spouse LJ Child LJ Father LJ Mother LJ Other LJ(Please Specify)
g) Occupation:ServiclJ SelfEmployecl_J
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HomemakeLJ StudenLJ RetiredlJ Other lJ(Please Specify) �-----�

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h) Address(if different from above) ____________________________ ()

City: I I I I I I I I State:I I I I Pin Code:�I �I �I���

l)PhoneNo: I I I I I I I J)EmaillD:_________________

DETAILS OF HOSPITALIZATION
a)Name of Hospital where Admitted:___________________________
Dr. Fehmida Nursing Home

b) Room Categoryoccupied:Day CarelJ Single occupancy LJ Twin sharing LJ

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3 or more beds per room LJ
c) Hospitalisation due to:Injury LJ lllnessLJ Maternity LJ
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d) Date of Injury/Date Disease first detected/Date of Delivery: l_QJ_QJ
1 9 � 1 1 I YI
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e) Date of admission 1 9 1 1I IY
l..Q1QJ � 0 2 4 0 7 2 1 �I
I I YI YIf) Timelti..ltiJ lMlli!Jg)Date of Discharge l..Q1QJ
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I)Name of treating doctor____________
Dr. Fehmida Diagnosis________________
Pregnancy

j) If injury give cause:SelflJ infiictedlJ Road Traffic AccidentlJ Substance Abuse /Alcohol ConsumptionlJ
i) If Medico legal:Yes LJ NolJ
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ii) Reported to police:YeslJ No lJ
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iii) MLC report and Police FIR attached:YesLJNolJ

✔ j) System of Medicine� ---------------
IV and Oral Medicine --'
 7 0 0 0 0

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7 0 0 0 0

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k) I/We authorize Insurance Company/TPA to contact me/us through SMS/Email/WhatsApp for any update on this claim.
Bajaj Allianz General Insurance Co. Ltd.
Bajaj Allianz House, Airport Road, Yerwada, Pune-411006. Reg.: 113 I CIN: U66010PN2000PLC015329
For more details, log on to: www.b ajajallianz.c om
II Allianz@)

Email id: [email protected]. Toll free no. 1800-209-5858, 020-30305858 Cru-�a-s-

CLAIM FORM- PART B

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TO BE FILLED IN BY THE HOSPITAL
The issue of this form is not to be taken as admission of liability
Please include the original preauthorization request form in lieu of PART-A o be filled in �ck letters)
DETAILS OF HOSPITAL
a) Name of the hospital : _________________________________________ (/J
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b) Hospital ID :_______________c) Type of hospital : Network D Non-Network D (If non-network fill section E) 0
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d) Name of treating doctor:.________________________________________ z

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e) Qualification: _________ f) Registration No with State Code_______ g) Phone No:_____________
h) Rohini Code________i) NABH CODE ________ j) State Level Certificate _______________
k) Higher Level Certificate_____l) National Quality Assurance Standards _____.m) National Health System Resource Center _____
DETAILS OF THE PATIENT ADMITTED
a) Name of the patient :._________________________________________
b) IP registration Number : ______ c) Gender: Male D Female □ d) Age :YearsW Months: W e) Date of birth: IDID IMI Ml YIYI (/J
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f) Date of admission: IDID IMI Ml YIYI g) Time : l.!i..1!iJ � h) Date of discharge : IDID IMI Ml YIYI i) Time: l.!i..1!iJ � 0
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j) Type of Admission : Emergency D Planned D Day Care D Maternity □ k) If Maternity i) Date of delivery! DIDIMI Ml YIYI ii)Gravida Status: LlJJ 0
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I) Status at time of discharge: Discharge to home D Discharge to another hospital D Deceased: □ m) Total claimed Amount I I I I I I I I
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DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i) Primary Diagnosis: i) Procedure 1:

ii) Additional Diagnosis: ii) Procedure 2:

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iii) Co-morbidities : iii) Procedure 3: 0
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iv) Co-morbidities : iv) Details of

Procedure:

d) Pre-AuthorizationObtained:Yes D No D e) Pre-Authorization Number: �I�����������

f) If authorization by network hospital no obtained, give reason:_____________________________

g) Hospitalization due to injury:YesD No D i)lf Yes give cause: Self-infiicted:D Road Traffic Accident: D Substance abuse/ alcohol consumption: D

ii) If injury due to Substance abuse/alcohol consumption, Test conducted to establish this:YesD NoO(1f Yes attach reports) iii)Medico Legal:YesD No D
iv)Reported to Police:Yes D No D v) FIR no: ____vi) if not reported to police give reason:________________

CLAIM DOCUMENTS -CHECK LIST

D Claim form duly signed D Ingestion reports
D Original Pre-Authorization request D CT/MR/USG/HPE investigation report
D Copy of Pre-Authorization letter D Doctor"s reference slip for investigation (/J
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D Copy of photo ID card of patient verified by hospital 0 ECG -I
D Hospital discharge summary D Pharmacy bills 0
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D Operation theatre notes 0 MLC report & Police FIR 0

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D Hospital main bill D Original death summary from hospital where applicable
D Hospital break up bill D Any other, please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)
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a) Address of hospital__________________________________________ m
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City:_____ State:______ Pin Code:___Phone No:_______ c) Registration no with State Code:--�=-� -I
d) Hospital PAN: e) Number of Inpatient beds:LlJ_JFacilities available in hospital: i)OT: YesD NoD ii) ICU:Yes D No D 0
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iii)Others:____________________________________________
DECLARATION BY THE HOSPITAL: (PLEASE READ VERY CAREFULLY)
We hereby declare that the information furnished in the Claim Form is true and correct to the best of our knowledge and belief. If we have made any false and untrue
statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited. (/J
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Date : D D M MI YI Y I 0
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Place : ________
Signature and Seal of the Hospital Authority i