Tata AIG Life Insurance Company Limited (hereinafter called Tata AIG or the Company, whichever is applicable)

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1 Policy.: Claim.: Tata AIG Life Insurance Company Limited (hereinafter called Tata AIG or the Company, whichever is applicable) HOSPITALIZATION CLAIM FORM Office Agency Code Agent Code PART I (To be completed by Insured/Claimant in BLOCK letters) Please answer all questions, use not applicable (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form. The filing of this claim form is not to be construed as an admission of liabilities of our Company. agent has been or is authorized to admit any liabilities on behalf of the Company. (te: - Insured s name should be written in full as the same will appear on the cheque) Policy. Full Name of Insured Age Alias, if any Sex Benefits to Claim: (please tick) Daily Hospital Benefit Post-Hospitalization Benefit Surgical Benefit Dismemberment Insured s Address I. D.. Contact Phone. I. D. Document Type Bank Account. Occupation & exact duties Employer Name & Address Contact Phone. Are you claiming from other insurers or institutions (including government/welfare schemes) for the same cause? Yes, for (type & amount) from from Did a medical leave certificate filed to Insured s employer? Yes, (state the dates) Claims Details Describe initial symptoms / parts of body injured Since when does the Insured have these symptoms / bodily injury MM DD YYYY Date of first consultation Diagnosis given by doctor MM DD YYYY The first doctor consulted (name, address & telephone) Is the condition due to an accident?. Yes, details below: Accident Date Time (am / pm) Place Accident Details MM DD YYYY Consultation Details a) Insured s regular doctor Name, Address & Telephone Consultation Dates Disease / Condition b) All other doctors consulted for this illness/injury; or similar condition in the past

2 c) Doctor who referred Insured to hospital Please give details of any other illness Insured have suffered from in the past. Disease/Condition Consultation Dates Doctor consulted (Name, Address & Telephone.) Hospitalization Details Details of hospital confinement for the injury/illness. Name of Hospital Address Date of consultation(s) Date & time of admission Date & time of discharge Any surgical procedure(s) done during hospitalization? Yes, details: Information of Claimant (if other than the Life Insured) [te:- Claimant name should be written in full as the same will appear on the cheque] Name in Full ID. ID Type Age Sex: Male Female Address Telephone. In what title are you submitting this claim? Relationship with the Insured Bank Account no. DECLARATION AND AUTHORIZATION I/We hereby declare that the information given on this accident/hospitalization claim application form is true and complete. /We hereby make claim to Tata AIG by submitting this accident/hospitalization claim application form and agree that the written statements of all the physicians who attended or treated the Insured and all other proofs and supporting documents associated with this accident/hospitalization claim application form shall constitute and are hereby made part of this accident/hospitalization claim application form. I/We further agree that the furnishing of this accident/hospitalization claim application form, or of any other forms supplemental hereto by the Company, shall not be deemed an admission of an existence of any assurance in force on the life in question, nor an admission of liabilities or a waiver of any of its rights of defenses. I/We hereby declare and agree that any personal information collected or held by the Company (whether contained in this application or otherwise obtained) is provided and may be held, used, and disclosed by the Company to individuals/organizations associated with the Company or any selected third party (within or outside of India, including reinsurance and claims investigation companies and industry associations/federations) for the purposes of processing this application and providing subsequent services for this and other financial products and services, direct marketing, and data matching, and to communicate with me/us for such purposes. I/We hereby irrevocably authorize: (i) any organization, institution, or individual that has any record or knowledge of my/the Insured s health and medical history or any treatment or advice and that has been or may hereafter be consulted, other personal information or details of related accident/injury to disclose to the Company such information; (ii) the Company and its approved medical examiners and laboratories to perform medical assessment and tests to evaluate Insured s health condition, or to perform any autopsy as appropriate. This authorization shall bind my/the Insured s successors and assigns and remain valid notwithstanding my/the Insured s heath or incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as the original. Witness Signature: Date: Name of Witness: (in block letters, family name first) Life Insured Signature: Date: Policyowner/Claimant (If other than life Insured) Signature: Name: (in block letters, family name first) Date: te: - Witness should be a tary/ Gazetted officer / SEM or a person of local standing.

3 Policy.: Claim.: Tata AIG Life Insurance Company Limited (hereinafter called Tata AIG or the Company, whichever is applicable) CERTIFICATE OF MEDICAL ATTENDANT To be completed in BLOCK letters by a duly qualified and registered medical practitioner at the claimant s expense. Please answer all questions, use not applicable (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form. Patient Name Age Sex Patient s Occupation Patient s Address I. D.. I. D. Document Type Consultation Details If due to ILLNESS, please provide: Chief complaints & presenting symptoms If due to ACCIDENT, please provide: Conditions of injury & parts of body involved Is there external visible evidence of injury at your first consultation: If yes, give details Date symptoms first appeared Your Diagnosis Date of injury Cause of injury Date of your consultation of this illness/injury First consultation on Last consultation on Past medical history, family history and co-morbid conditions (please give consultation dates & details) Hospitalization Details Does this illness/injury necessitate inpatient hospitalization: Yes, details as below:- Hospital Name Date & Time of Admission Address Date & Time of Discharge Any surgical procedure performed? Yes, details as below:- Date of operation Place of operations Name of surgical procedure Surgeon Name & Registration. Tests & investigations performed? Yes, details as below:- Name of test/investigations Date(s) Results (please enclose a certified true copy of the test results) Other treatments administered (medicines, dressing & suturing etc) Discharge summary & treatment plan Dates of follow-up consultations with you after hospital discharge for the same illness/injury Date(s) Condition

4 Was healing complicated? Yes, details as below:- If yes, state reasons and any special treatment given. Bearing in mind the patient s occupation, do you feel the illness/injury would have prevented him/her from working at your first consultation at your last consultation If absence from work more than 2 weeks was necessary, please state the reasons. Is the illness/injury related to (a) Physical defects/congenital anomaly (b) Unfavourable past medical history (c) Degenerative changes (d) Alcohol, drug, or nicotine/smoking (e) AIDS or HIV infection Yes, details: Yes, details: (f) Suicide or self-inflicted injury Other doctors/hospitals involved in the care of the patient Name Address Telephone. Declaration by the Attending Physician/Specialist I declare that the answers given are true and complete. I declare I am duly licensed and registered to practice western medicine (allopathy) in India (if outside India, please state where ) Certification by Hospital Admitted, that 1) The Hospital is duly licensed and registered as a Hospital to provide treatment in western medicine (allopathy) in India (if outside India, state where ) for the care and treatment of sick and injured persons as registered in-patients, fully equipped with facilities for diagnosis and major surgery which are under the constant supervision of one or more Registered Medical Practitioners, and which have 24-hour a day full time professional nursing services; And 2) Maintains proper medical and patient records and quality health care to the standards as required under the prevailing laws and regulations in the geographical area it is located; And 3) Is not an institution operated as a convalescent or rest home, a hotel, a home for the aged, a place for alcoholics or drug addicts, or Custodial Care, or for any similar purpose. 4) The Hospital has on the following facility and resource (please state). of in-patient beds :. of qualified registered resident doctors:. of qualified registered full time nurses : Signature of Attending Physician/Specialist (with qualifications) [Name in Block: ] Signature of authorized Hospital Administrator [Name in Block: ] Registration. & Place Address & Official Stamp Telephone Mobile. Address Date Name of Hospital Registration. & Place Address & Official Stamp Telephone Fax. Address Date

5 Hospital Information Sheet Name of hospital : Registration no. & Registering authority & Place : Address : Tel.. : Fax no. : Web site : Name of contact person : Designation : Telephone no. : address : Name of Owner (if different from contact person above) : The Hospital provide treatment in (tick as appropriate) : western medicines (allopathy) alternate medicines (state details) Specialties available (e.g. Paediatrics, Orthopaedics, ENT etc) If yes, please state details:. of in-patient beds:. of qualified registered resident doctors : For government hospitals, please also state. of Professor doctors:. of Assistant Professor doctors:. of Lecturer doctors:. of qualified registered full time nurses : In House facility available [please state Yes in the right column if available] Pathology Lab. : Oxygen : - Central supply : - Cylinder : E. C. G. : X Ray : Ultrasonography : C. T. Scan : M. R. I. Scan : Pathology :.

6 Blood Bank : Operation Theatre : Labour room / delivery room : I. C. C. U.: Cardiac monitor : Defibrillator : Ventilator : Emergency Room : Day Care Centre : Outpatient consultation : Computerized access to patient records : Other facilities please state details : The above information is certified to be true and complete. Signature of Hospital Administrator Date [Name in Block: ] Hospital Name & Official Stamp.

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