THE NEW INDIA ASSURANCE CO. LTD.,
(Regd & Head Office:_ New India Assurance Bldg., 87, M.G. Road Fort, MUMBAI 400 001)
Underwriting office: DO 120700, New India Centre, 8th Foor, 17- A, Cooperage Road, Mumbai 400 039
LIC Mediclaim Insurance Policy - Claim Form
(Issuance of this form does not assure admission of liability)
1. Name of the employee / Retired employee:__________________________________________
2. Salary Roll No. (S.R. No.):_____________ Cadre:____________________________
3. Email id* :__________________________________; Mobile no*:_________________________
4. Place of working: Place __________ CO/ZO/DO/BO (Code) ______________ ___
5. Residential Address :__________________________________________________
_______________________________________________________________________
6. Name of the Patient :_____________________________________ ____________
7. Relationship with the claimant : _______________________________
8. Nature of illness / accident: _________________________________________________
9. Date of Admission :__________________ Date of Discharge: _______________
10. Total Sum Insured :Rs.________________ Amount claimed :Rs.______________
11. Claim amount received earlier during the current year:____________________________
12. No. of living children as on date______________________
*Please provide the email id, mobile no for receiving information from the TPA about the claim
(For maternity related claims)
I have incurred the above expenses on the treatment of illness / accident referred above, in support of which I
enclose the following documents in original:-
1. Discharge card / Discharge summary from Hospital (Xerox copy attested by Class I officer / OS shall be
accepted)
2. Hospital bills and Receipts, Pathological tests bills and receipts
3. Attending doctors / surgeons / Anaesthetists bills and receipts and certificate stating the diagnosis
4. Cash memos / Chemists Bills duly supported by prescriptions
5. Pathological test reports, X ray reports and attending doctors note requesting for such tests/reports
6. Any other documents related to the claim.
7.
DECLARATION
I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I make any false or
untrue statement, suppression or concealment, my right to re-imbursement shall be absolutely forfeited. I further
declare that, in respect of the above treatment, no benefits are / will be claimed under any other Medical
Insurance.
DATE:
SIGNATURE OF THE EMPLOYEE/RETIRED EMPLOYEE
____________________________________________________________________________________
(TO BE FILLED BY LIC)
We certify that the Person mentioned below is a bonafide employee/ dependent of the employee / retired
employee / spouse of retired employee of LIC of India and the details of insurance coverage are correct as per
our records, as given below:
1. Name of the employee / retired employee:
2. Name of the patient:__________________Relationship with the
employee___________________________
3. Covered with effect from Date: __________________ Compulsory Sum Insured: ________________
4. Total Sum Insured :_______________________________
5. No. of living children (In case of maternity claims) :________________________
SIGNATURE:________________________ DATE:____________________________________
NAME AND DESIGNATION: ____________________________________________________
LIC OFFICE CODE AND SEAL / ADDRESS:
