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. byTowardsAmount (Rs)DETAILS OF PRIMARY INSURED S BANK ACCOUNT::SECTION CSECTION DSECTION ESECTION FSECTION :State:Pin CodePhone No:Email ID:City:State:Pin CodePhone No:Email ID:DDDDMMMMYYYYYesNoYesNoYesNod) Name:SURNAMEFIRST NAMEMI DDLENAMEa) Name:SURNAMEFIRST NAMEMIDDLENAMEb) GenderMaleFemalec) Age yearsMMYYYYM onthsd) Date of Birthe) Relationship to Primary insured:SelfSpouseChildFatherMotherOther (Please Specify)(Please Specify)OtherRetiredStudentHome MakerSelf EmployedServicef) Occupationg) Address (if diffrent from above) :a) Name of H

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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