CLAIM FORM - paramounttpa.com
CLAIM FORM - PART A' to ' CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART ATO BE FILLED BY THE INSUREDThe issue of this Form is not to be taken as an admission of liablityDETAILS OF PRIMARY INSURED:a) Policy No.:(To be Filled in block letters)SECTION ASECTION Bb) Sl. No/ Certificate ) Company/ TPA ID No:e) Address:DETAILS OF INSURANCE HISTORY:a) Currently covered by any other Mediclaim / Health Insurance:b) Date of commencement of first Insurance without break:c) If yes, company name:Policy insured (Rs.)d) Have you been hospitalized in the last four years since inception of the contract?Diagnosis:e) Previously covered by any other Mediclaim /Health insurance : :Date:MMYYYYf) If yes, company name:DETAILS OF INSURED PERSON HOSPITALIZED: :DETAILS OF HOSPITALIZATION: :DETAILS OF CLAIM :DETAILS OF BILLS ENCLOSED:Sl.
claim form - part a' to 'claim form for health insurance policies other than travel and personal accident - part a to be filled by the insured
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