EMP Code*
Full Name*
Policy No*
Card No*
Email*
Phone Number*
Sum Insured
SI Balance
Topup - SI
Topup Balance
Dom Sum Insured
Dom Balance
Pancard
Patient Name*
Select
Self
Select
Self
Employee Location Name
Select
Head Office
R&D Gurgaon
R&D Hyderabad
RSO- North
RSO- East
RSO- South
RSO- West
Nabha
Rajahmudary
Sonepat
Relation
Dependent Name*
Dependent Card No.
Bank Details:
Bank Name*
IFSC Code*
A/c Holder Name*
Account Number*
Claim Type*
Select
Hospitalization
Domiciliary
Hospitalization
Name of Hospital*
Address*
Name of Patient*
Age*
Date of Admission*
Time
Date of Discharge*
Time
Name of Disease*
Hospitalisation Charges
Room & Board/day
No of days
Cost of Medicine
Nursing Attendance Charges
Other Expenses
Total
Surgeon's Fee
Name of Surgeon
Name of Surgical Operation
Performed at Hospital
Performed on date
Opration Charges
OTC maximum limit is Rs. 2000/-
Incidental Expenses
Total
Special Services
Anaesthesia
Oxygens
Blood Transfusion
Use of OT charges
Surgical Appliance & Eye Glasses
Medicine & Injections
X-Ray
Please send hard copy of reports with original claim docs.
Pathological
Please send hard copy of reports with original claim docs.
E.C.G
Please send hard copy of reports with original claim docs.
Total
Consultation Fees of Medical Practioners/Specialists
Name of Medical/Practioner/Consultant
Dignosis Charges
Consultation on date
Charges
Consultation on date
Charges
Consultation on date
Charges
Consultation on date
Charges
Consultation on date
Charges
Total
Total Claim Amount:
Domiciliary
Name of Physician*
Address*
Qualification & Regd No.
Name of Patient*
Age*
Diagnosis
Location
Duration of Treatment from
Duration of Treatment to
Surgeon's Fee
Doctor's Fees
Cost of Medicines
X-Ray
Please send hard copy of reports with original claim docs.
E.C.G
Please send hard copy of reports with original claim docs.
Pathological Test
Please send hard copy of reports with original claim docs.
Other Test
Please send hard copy of reports with original claim docs.
Total
Eye/Dental/OTC Treatment
Treatment Type
Select
Eye
Dental
OTC
DOMICILIARY
Eye-Cosmetic Treatment
Dental-Cosmetic Treatment
OTC maximum limit is Rs. 2000/-
Dentist/Specialists/Spec Fee
Cost of Medicines
X-Ray
Please send hard copy of reports with original claim docs.
Other Test
Please send hard copy of reports with original claim docs.
Total
Total Claim Amount: