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Critical Illness Claim Form: Issuing Office

This document is a critical illness claim form from National Insurance Company Limited. It requests information such as the name and address of the insured person, policy number, details of the illness or injury, treating medical professionals, dates of diagnosis and admission/discharge from the hospital, and a confirmation of the diagnosis from the doctor. The claimant must sign declaring the truth of the provided particulars and that no other medical insurance benefits are being claimed for the same treatment.

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61 views2 pages

Critical Illness Claim Form: Issuing Office

This document is a critical illness claim form from National Insurance Company Limited. It requests information such as the name and address of the insured person, policy number, details of the illness or injury, treating medical professionals, dates of diagnosis and admission/discharge from the hospital, and a confirmation of the diagnosis from the doctor. The claimant must sign declaring the truth of the provided particulars and that no other medical insurance benefits are being claimed for the same treatment.

Uploaded by

Sadasivuni007
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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National Insurance Company Limited

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata


700 071
CIN - U10200WB1906GOI001713 IRDA Regn. No. - 58

Issuing office

CRITICAL ILLNESS CLAIM FORM


1. Name and address of the Insured

2. Details of the Insured Person:


(in respect of whom claim is made)

(A) Name and relationship to the


insured

(B) Completed age at present:

© Occupation:
(C) Residential address

3. Policy No.
4 Nature of disease / illness contracted
or
Injury suffered:

5. Date of injury sustained or disease


illness first detected

(A) Name and relationship to the


insured
(B) Completed age at present

(C) Residential address

6. ( a ) Name and address of the Medical


practitioner

( b ) Qualification & Telephone No.


( c ) Registration No
7. ( a ) Name and address of the
Hospital/ Nursing Home/Clinic:
( b ) Date and time of admission
( c ) Date and time of Discharge:
8. Name of the disease contacted:
9. Date of Diagnosis made:
10 Name of the Institution giving the
Diagnosis

11 Certificate from the doctor confirming


the Diagnosis attached

12 Present condition of the patient:

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have
made or shall make any false or untrue statement, suppression or concealment, my right to claim
reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect
of the above treatment, no benefits are admissible under any other Medical Scheme or
Insurance.

Place :

Date : Signature of the Claimant

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