Transcription of Claim Form May2019 - Bajaj Allianz General Insurance
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Claim Form May2019 - Bajaj Allianz General Insurance
Claim form FOR HEALTH Insurance POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT part ATO BE filled IN BY THE insured The issue of this form is not to be taken as an admission of liabilityEmail free no:1800-209-5858020-30305858(To be filled in block letters)DETAILS OF PRIMARY INSUREDa) Policy No: b) Sl. No/Certificate No:c) Company TPA ID No:e) Company Name:_____f) Employee No:_____g) Name: h) Address:City:State: Pin Code: Phone No: Email ID:_____ d) Customer ID:DETAILS OF Insurance HISTORYa) Currently covered by any other Mediclaim / Health InsuranceYesNo b) date of commencement of first Insurance without breakc) If yes, company name:Policy No:Sum insured (Rs.
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 Email id:-customercare@bajajallianz.co.in Toll free no:1800-209-5858 020-30305858 (To be filled in block letters) DETAILS OF PRIMARY INSURED
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