TTK Healthcare TPA Private Limited

Size: px
Start display at page:

Download "TTK Healthcare TPA Private Limited"

Transcription

1 TTK Healthcare TPA Private Limited Page -1 of 4 #2, H.B Complex,100 Feet BTM Ring Road,BTM First Stage, BTM Lay Out,Bangalore , PH: CLAIM FORM Form no : 9 TTK ID No : (Issuance of this Claim Form is not tantamount to acceptance of Liability by the Insurer) Name & Address of the Insured : (in whose name policy is issued) Details of Insured Person : (in respect of whom claim is made) a) Name & relationship of the Insured b) Present completed Age c) Occupation d) Contact Address e) Phone No f) Mobile No g) Address Name of the Insurance Company Policy No. Serial No. Of the Schd/ Certificate No:: AILMENT / DISEASE / INJURY: Date of Injury sustained or disease / illness first detected: - Name of the Hospital : a) Have you been insured under any mediclaim scheme earlier (held with us or any other insurance co.) If yes, xerox copies of previous years' policies MUST be enclosed. b) Date of commencement of very first insurance for this person with with continous insurance coverage. Have you preferred any claim for the same insured under the mediclaim scheme earlier, if so, give the following details: a) Previous claim file ref.no/office : b) Diagnosis : c) Whether settled/repudiated : d) Amunt (if settled) :Rs. Date of Admission Date of Discharge : Time of Admission Time of Discharge: TOTAL AMOUNT CLAIMED : Rs. If the claim is of Domiciliary Hospitalization please indicate a) Date of Commencement of the treatment b) Date of Completion of treatment c) Name & Address of attending Medical Practioner with Telephone No. & Registration No. Signature of the claimant

2 1 of 4 I have incurred the below expenses for the treatment of the disease / illness / accident and herewith as per schedule mentioned below: - Page -2 of 4 Schedule of Expenses incurred by the Claimant Date Bill No. Description Amount Claimed. FOR TTK USE ONLY In support of the claim, I enclose the following documents Yes / No Yes / No Claim form Duly Signed Pre Hospitalization Bills & N0(s) of Bills TTK Pre-authorization form Post Hospitalization Bills & N0(s) of Bills Claim Notification Hospital Payment Receipt Discharge Summary Investigation Reports with Dr s request Hospitalization Bills 1. MRI Yes / No 2. CT Scan Yes/ No Doctors Surgery Certificate if any 3. ECG Yes/No 4. X-ray Yes/No 5.US Scan Surgery / Consultation Bills if any Lab Reports with Dr s request N0(s).. of Reports Operation Theatre Pharmacy bills Others if any Medicines bills with Dr s prescription Previous Policy Numbers if any: I hereby declare that the above information is true & correct to the best of my knowledge and belief. If I have made any false, fraud or untrue statement, suppression or concealment, my right to claim reimbursement of the expenses shall be forfeited. I also consent and authorise TTK / Insurance company to seek medical information from any Hospital/ Medical Practitioner who has at any time attended on the insured person. I hereby declare that I have included all bills/ receipts for the purpose of this claim and that I will not be making any supplementary claim in respect thereof, except the post Hospitalisation claim if any. Date Signature of the Claimant 2 of 4

3 TTK Healthcare TPA Private Limited Page -3 of 4 MEDICAL CERTIFICATE TO BE FILLED IN BY THE DOCTOR TREATING THE PATIENT 1. Name of the patient and Age 2. Date of Admission 3. Date of Discharge Time of Admission Time of Discharge 3. Name of surgeon/physician 4. Diagnosis 5. Date of First consulatation (PRIOR TO HOSPITALISATION) 6.(A) With what complaints was the patient admitted for: (B) Since When was the patient suffering from the said complaints 7. Past History of the patient (if any) with the duration of illness 8. Whether the present ailment is a complication of pre-existing disease? If yes, please specify the disease (or) complication of any previous surgery done? If yes, please specify the details 9. Whether the disease/disorder is congenital in nature? 10. Nature of Surgery/Treatment given for the present ailment 11. (a) whether Hospital/Nursing home is Registered, if yes, Regn.No. (b) No of in patient beds in the Hospital (including ICU) Whether the Hospital is having fully equipped Operation Theatre of its Own/ Qualified Nurses Round the clock/ Qualified doctors round the Clock? Signature of the Doctor with Seal 3 of 4

4 Page -4 of 4 TTK Healthcare Services Private Limited #2, H.B Complex,100 Feet BTM Ring Road,BTM First Stage, BTM Lay Out,Bangalore , PH: To: THE HOSPITAL NAME AND ADDRESS Dear Sirs, Re: AUTHORISATION TO TTK HEALTHCARE SERVICES PVT. LTD. I have undergone treatment for from to in your hospital. I hereby authorise M/s.TTK Healthcare Services P Ltd., who are my TPS for the Mediclaim plicy I have, to seek any medical information / records from you or from the Medical Practitioners who have attended on me in connection with the above ailment. In case they seek any such information / records kindly oblige. Thanking you, Yours faithfully, (Signature of the Claimant) Address of the Insured: 4 of 4

5 ELECTRONIC CLEARING SERVICE (CREDIT CLEARING) MANDATE FORM CUSTOMER S OPTION TO RECEIVE PAYMENTS UNDER GOOD HEALTH POLICY THROUGH CREDIT CLEARING MECHANISM For Claim under Policy No. Certificate No. 1. (A) CARDHOLDER S NAME : (B) ADDRESS : (C) TELEPHONE/MOBILE NO. : (D) ID : 2. TTK ID NO. : 3. PARTICULARS OF BANK ACCOUNT: (A) BANK NAME : (B) BRANCH NAME: (C) ADDRESS: (D) 9 DIGIT CODE NUMBER OF THE BANK & BRANCH APPEARING ON THE MICR CHEQUE ISSUED BY THE BANK (E) ACCOUNT TYPE ( SAVINGS ACCOUNT/CURRENT ACCOUNT): (F) ACCOUNT NUMBER (AS APPEARING ON THE CHEQUE BOOK: 4. DATE OF EFFECT : 5. IFSC CODE (INDIAN FINANCIAL SYSTEM CODE) INFORMATION FOR PAYMENT THROUGH RTGS OR NEFT 6. NEFT CODE (NATIONAL ELECTRONIC FUNDS TRANSFER CODE) By submission of the above,i authorise M/s TTK Healthcare Services/The New India Assurance Co. Ltd to settle the claim under reference through direct payment by ECS. I hereby declare and confirm that the particulars given above are correct and complete. I agree that I shall not hold the TPA/Insurance Company responsible for delay or non receipt of payment for any reason whatsoever after issue of instructions for transfer of payment by Insurer/TPA based on the above. Place: Signature of the insured (Citibank credit card holder)

3. Corporate Name : Employee Code : 4. Name & Address of the Policy Holder: 5. Name of the Patient: 6. Present Contact Address:

3. Corporate Name : Employee Code : 4. Name & Address of the Policy Holder: 5. Name of the Patient: 6. Present Contact Address: MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD. S. No. 46/1, E-space, A Wing, 3rd Floor, Pune Nagar Road, VadgaonSheri, Pune - 411014 (Maharashtra) UAN Voice : 1860-233-4446 UAN Fax: 1860-233-4447 Email: customercare@mdindia.com

More information

TATA AIG General Insurance Company Limited Address CLAIM FORM

TATA AIG General Insurance Company Limited Address CLAIM FORM CLAIM FORM CLAIM FORM PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability SECTION A DETAILS OF PRIMARY INSURED a) Policy No b) Sl. No/ Certificate

More information

PART A TO BE FILLED IN BY THE INSURED / INSURED PERSON. (The issue of this form is not to be taken as an admission of liability)

PART A TO BE FILLED IN BY THE INSURED / INSURED PERSON. (The issue of this form is not to be taken as an admission of liability) Group Medisure Insurance Claim Form Toll Free Number 1800-209-5846 (1800-209-LTIN) Website www.ltinsurance.com SMS LTI to 5607058 (56070LT) GUIDELINES TO FILL THE FORM 1. Please fill the form in BLOCK

More information

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A SBI General Insurance Company Limited IRDA Reg. No. 144 dated 15/12/2009 CIN: U66000MH2009PLC190546 CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A TO BE FILLED

More information

Claim Form-Part A DETAILS OF PRIMARY INSURED (SECTION A) DETAILS OF INSURANCE HISTORY (SECTION B) DETAILS OF INSURED PERSON HOSPITALIZED (SECTION C)

Claim Form-Part A DETAILS OF PRIMARY INSURED (SECTION A) DETAILS OF INSURANCE HISTORY (SECTION B) DETAILS OF INSURED PERSON HOSPITALIZED (SECTION C) MediPrime Best Product Innovation Award The Indian Insurance Awards 2013 Claim Form-Part A To be filled in by the insured The issue of this Form is not to be taken in as admission of liability (To be filled

More information

Reliance Wealth + Health Plan

Reliance Wealth + Health Plan Reliance Wealth + Health Plan CLAIM FORM MAJOR SURGICAL BENEFIT (To be filled in block letters by the Claimant/Principal Insured) S.NO POLICY NO. 1. Name of the Policy holder 1a. Date Of Commencement of

More information

To Download our Insurance Network List Click Here

To Download our Insurance Network List Click Here We at BizWorld recommend HealthFirst-Cover more for you and your family to cover all the unexpected medical expenses and tragedy that might occur unplanned or planned. With HealthFirst-Cover More at your

More information

Easy Domestic Travel Insurance

Easy Domestic Travel Insurance Issuance of this form does not amount to admission of any liability or a waiver of any of the terms and conditions of the Policy. If any claim is in any manner dishonest or fraudulent, or is supported

More information

ICICI LOMBARD GENERAL

ICICI LOMBARD GENERAL Group Health Insurance Policy ICICI LOMBARD GENERAL INSURANCE CO LTD. TRAVELEX INDIA PVT LTD 1 ST JAN 2013 to 31 st Dec 2013. 1 of 14 Contents Terminology. Scope of coverage. Policy terms and conditions.

More information

BIRLA SUN LIFE INSURANCE COMPANY LIMITED CLAIMANT S STATEMENT FORM (DEATH CLAIMS)

BIRLA SUN LIFE INSURANCE COMPANY LIMITED CLAIMANT S STATEMENT FORM (DEATH CLAIMS) BIRLA SUN LIFE INSURANCE COMPANY LIMITED CLAIMANT S STATEMENT FORM (DEATH CLAIMS) Points to Note This form is to be filled in by the beneficiary under the policy or by the person legally entitled for the

More information

Critical Illness Health Insurance Claims - Reliance General Insurance

Critical Illness Health Insurance Claims - Reliance General Insurance Critical Illness Health Insurance Claims - Reliance General Insurance http://www.reliancegeneral.co.in/insurance/health-insurance/critical-illness/claim-procedure-health-insurance.aspx Critical Illness

More information

Claim Form CLAIM FORM PART A TO BE FILLED IN BY THE INSURED. www.apollomunichinsurance.com

Claim Form CLAIM FORM PART A TO BE FILLED IN BY THE INSURED. www.apollomunichinsurance.com CLAIM FORM (The issue of this Form is not to be taken as an admission of liability) PART A TO BE FILLED IN BY THE INSURED SECTION A - DETAILS OF PRIMARY INSURED a) Policy No. : b) Sl. No/ Certificate No.

More information

1) Who is a United India TPA? And How will I know my United India TPA?

1) Who is a United India TPA? And How will I know my United India TPA? FAQ S on Medical Insurance Scheme 1) Who is a United India TPA? And How will I know my United India TPA? Third Party Administrator is An IRDA licensed TPA who is engaged by the Insurance Company in Servicing

More information

Health Insurance Orientation Module. Future Generali Health

Health Insurance Orientation Module. Future Generali Health Health Insurance Orientation Module Introduction Future Generali is an insurance joint venture between the Italy-based Generali Group and the India-based Future Group. Future Generali operates Life and

More information

Easy Travel Insurance

Easy Travel Insurance Issuance of this form does not amount to admission of any liability or a waiver of any of the terms and conditions of the insurance contract. If any claim is in any manner dishonest or fraudulent, or is

More information

Tata AIA Life Insurance Company Limited (hereinafter called the Company ) DEATH CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT

Tata AIA Life Insurance Company Limited (hereinafter called the Company ) DEATH CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT Tata AIA Life Insurance Company Limited (hereinafter called the Company ) DEATH CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT Guidelines / Notes: 1. Death benefit is payable subject to policy being inforce

More information

Death Claim Application Form

Death Claim Application Form Death Claim Application Form Please accept our condolences on your untimely loss. We understand that this is a difficult time for you and it is our responsibility to offer you the best support in this

More information

Claim Filing Instructions & Claim Form

Claim Filing Instructions & Claim Form Claim Filing Instructions & Claim Form Please follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the IMG Customer Service Department

More information

HANDOUT-DEATH CLAIM. Our mailing address is as follows. Claims Department, Aviva Life Insurance Company India Limited,

HANDOUT-DEATH CLAIM. Our mailing address is as follows. Claims Department, Aviva Life Insurance Company India Limited, HANDOUT-DEATH CLAIM KIND ATTENTION: CLAIMANT We deeply regret the sad demise of your loved one. We assure you of our support throughout the claims process to help and assist you to complete the formalities

More information

Death Claim Application Form

Death Claim Application Form Death Claim Application Form Please accept our condolences on your untimely loss. We understand that this is a difficult time for you and it is our responsibility to offer you the best support in this

More information

INDIVIDUAL PERSONAL ACCIDENT INSURANCE POLICY Claim Form

INDIVIDUAL PERSONAL ACCIDENT INSURANCE POLICY Claim Form SBI General Insurance Company Limited IRDA Reg. No. 144 dated 15/12/2009 CIN: U66000MH2009PLC190546 INDIVIDUAL PERSONAL ACCIDENT INSURANCE POLICY Claim Form Call (Toll Free) 1800 22 1111 1800 102 1111

More information

Health Insurance Policies

Health Insurance Policies Standard Definitions of Terminology used in Health Insurance Policies PUBLISHED IN THE GUIDELINES ON STANDARDISATION IN HEALTH INSURANCE VIDE IRDA CIRCULAR NO: IRDA/HLT/CIR/036/02/2013 DATED 20.02.2013

More information

Total and Permanent Disability claim form

Total and Permanent Disability claim form Total and Permanent Disability claim form 1. Notice Of Claim Written notice of claim must be given to AXA Life within 90 days from the date of disability certified by a specialist in the relevant field.

More information

PART A TO BE FILLED IN BY THE INSURED. (The issue of this form is not to be taken as an admission of liability) S T D D D M M Y Y Y Y

PART A TO BE FILLED IN BY THE INSURED. (The issue of this form is not to be taken as an admission of liability) S T D D D M M Y Y Y Y Medisure Classic Insurance Claim Form Toll Free Number 1800-209-5846 (1800-209-LTIN) Website www.ltinsurance.com SMS LTI to 5607058 (56070LT) GUIDELINES TO FILL THE FORM 1. Please fill the form in BLOCK

More information

Once we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible.

Once we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible. ACCIDENT CLAIM FORM Dear Claimant, We are sorry to learn of your accident. In order for us to process your claim, we require the following: 1) Claimant s Statement. 2) 1 Clinical Abstract Application Form.

More information

LHMU Accidental Dental Claim Form

LHMU Accidental Dental Claim Form LHMU Accidental Dental Claim Form DENTAL BENEFIT CLAIM In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields completed.

More information

CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE

CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE (The issuance of this form is not to be taken as an Admission of Liability) Address to dispatch Claim Documents : ICICI Lombard Health Care ICICI Bank Tower,

More information

Claim form. Overseas Officers Insurance Policy. Accidental Death and Capital Benefits and Compassionate Travel YOUR DETAILS

Claim form. Overseas Officers Insurance Policy. Accidental Death and Capital Benefits and Compassionate Travel YOUR DETAILS Claim form Overseas Officers Insurance Policy Accidental Death and Capital Benefits and Compassionate Travel M U T U A L B R O K E R S P T Y L T D Arranged by Mutual Brokers ABN 73 008 602 266 AFSL Number

More information

Can my whole family be covered under a single Health policy? Yes! In fact a family package discount is also available in many policies.

Can my whole family be covered under a single Health policy? Yes! In fact a family package discount is also available in many policies. What is Health Insurance? Health Insurance is protection against medical costs. A health insurance policy is a contract between an insurer and an individual /group in which the insurer agrees to provide

More information

PERSONAL ACCIDENT AND/OR SICKNESS CLAIM FORM

PERSONAL ACCIDENT AND/OR SICKNESS CLAIM FORM We are pleased to enclose a claim form as requested. PERSONAL ACCIDENT AND/OR SICKNESS CLAIM FORM Most delays in settling claims arise because claim forms are not fully completed or requested documents

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: Claim Number: 01PO527349 PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised representative of Willis

More information

PERSONAL ACCIDENT BENEFITS CLAIM FORM

PERSONAL ACCIDENT BENEFITS CLAIM FORM PERSONAL ACCIDENT BENEFITS CLAIM FORM Please note that we have to ensure that our claim form covers all types of claims. If you do not consider a question to be relevant to your circumstances please enter

More information

SINGLE/MULTITRIP TRAVEL

SINGLE/MULTITRIP TRAVEL SINGLE/MULTITRIP TRAVEL CLAIM FORM FOR MEDICAL EXPENSES AND TRIP INTERRUPTION Once completed, please return your claim to: claims@americanassist.com FAX: 1 305 749 0475 Mail address: 2250 NW 136 Av. Suite

More information

SHRAVAK AROGYAM PHASE-II

SHRAVAK AROGYAM PHASE-II FREQUENTLY ASKED QUESTIONS 1. About JIO? JIO is a vibrant organization for total unity of Jains, to serve all living beings & bring all round progress. JIO intends to be the global organization of visionaries

More information

PERSONAL INJURY INSURANCE CLAIM FORM FOR

PERSONAL INJURY INSURANCE CLAIM FORM FOR PERSONAL INJURY INSURANCE CLAIM FORM FOR Please ensure all sections are fully completed prior to submitting your claim. Failure to complete all sections of this form may delay settlement of your claim.

More information

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE You fully complete every question before your doctor completes his statement.

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: 0028332 Claim Number: s PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TENPIN BOWLING AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised

More information

INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM

INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM Dear claimant, We are sorry to learn about your disability. In order for us to process your claim, we require the following: (1) Claimant s Statement

More information

PERSONAL ACCIDENT CLAIM FORM - MEMBERS

PERSONAL ACCIDENT CLAIM FORM - MEMBERS Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important

More information

1 Please ensure that the club Secretary/Treasurer completes the Official Report section of the claim form.

1 Please ensure that the club Secretary/Treasurer completes the Official Report section of the claim form. Playeraccident claimform Our Head Office and registered address is: Sportscover Europe Ltd 3 rd Floor, PO Box HQ420, St Helen s, 1 Undershaft, London, EC3P 3DQ Registered in England and Wales. 3726678

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy NO: CANO01SII-0613 Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR : V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised representative of

More information

JLT SPORT. How To Make A Claim. Public Liability, Professional Indemnity and Associations Liability Claims

JLT SPORT. How To Make A Claim. Public Liability, Professional Indemnity and Associations Liability Claims How To Make A Claim JLT SPORT Public Liability, Professional Indemnity and Associations Liability Claims It is essential that you notify JLT Sport immediately of any potential claim. It is also extremely

More information

Absence from Work / Accidental Injury - Claim Form

Absence from Work / Accidental Injury - Claim Form Protection Absence from Work / Accidental Injury - Claim Form Please answer the following questions fully to avoid delay in considering your claim. If you fail to disclose all relevant information or if

More information

Maritime Super Income Protection Claim Form

Maritime Super Income Protection Claim Form Maritime Super Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all

More information

Claim Filing Instructions & Claim Form

Claim Filing Instructions & Claim Form Claim Filing Instructions & Claim Form Please follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the International Medical Group (IMG

More information

Email. Name of Intermediary (if any) Gender Male Female Age Date of Birth D D / M M / Y Y Y Y. Date of Employment D D / M M / Y Y Y Y.

Email. Name of Intermediary (if any) Gender Male Female Age Date of Birth D D / M M / Y Y Y Y. Date of Employment D D / M M / Y Y Y Y. TRAVEL INSURANCE Claim Form *SG021* *SG021* TO FACILITATE THE PROCESSING OF YOUR CLAIM, YOU ARE REQUIRED TO COMPLETE SECTIONS A, B AND C FOR ALL CLAIM SUBMISSIONS. The issue and acceptance of this form

More information

INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM

INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM Dear claimant, We are sorry to learn about your hospitalization. In order for us to process your claim, we require the following: (1) Claimant s Statement (2)

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: ATCSI00035 Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TABLE TENNIS AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised

More information

Personal Accident / Sickness Claim Form

Personal Accident / Sickness Claim Form Personal Accident / Sickness Claim form All relevant sections are to be answered in full. Please print your answers. The company does not admit liability by the issue of this form. It is issued to enable

More information

The issue and acceptance of this form does NOT constitute an admission of liability by ACE or waiver of its rights. Email Name of Agent/Broker

The issue and acceptance of this form does NOT constitute an admission of liability by ACE or waiver of its rights. Email Name of Agent/Broker WORK INJURY COMPENSATION Claim Form IMPORTANT INFORMATION 1) Insured is requested to state, as fully and accurately as possible, the information asked for below. *SG011* *SG011* 2) If any detail or information

More information

PETANQUE FEDERATION AUSTRALIA LTD

PETANQUE FEDERATION AUSTRALIA LTD Willis Australia Limited ABN: 90 000 321 237 AFS License Number 240600 Office use only Claim Number:. PETANQUE FEDERATION AUSTRALIA LTD PERSONAL INJURY CLAIM FORM Willis Australia Limited HEAD OFFICE Level

More information

SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM

SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM The issue or acceptance of this form is not construed as an admission of liability on the part of the Company. Please print clearly. To avoid delays please

More information

First Notice of Claim for Illness or Injury

First Notice of Claim for Illness or Injury How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents required Section A: Statement of claimant

More information

Travel Insurance Claim Form

Travel Insurance Claim Form CLAIMAINTS DETAILS Policy Number Departure Date Return Date Title First Name Surname ID / Passport Number Email Address Mobile Number Business Contact No Home Contact No Fax No Postal Address Postal Code

More information

How To Write A Claim For Hospital Expenses

How To Write A Claim For Hospital Expenses In-patient, Day-case & Surgical Out-patient Treatment Claim Form In order to make a claim Affix Hospital Label Here Please answer all the questions below, complete the relevant sections, read and sign

More information

AIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM

AIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM AIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM Important Notes: 1) AIA HealthShield Gold claims for Singaporeans and Permanent Residents must be submitted electronically via the medical institutions

More information

CRITICAL ILLNESS CLAIM FORM

CRITICAL ILLNESS CLAIM FORM CRITICAL ILLNESS CLAIM FORM Critical Illness Claim Form - Instructions Policyholder (employer or plan administrator) Please complete the Policyholder s Statement and ensure that you answer each question

More information

Goodman Fielder Income Protection Claim Form

Goodman Fielder Income Protection Claim Form Section A Claimant s Section Goodman Fielder Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The

More information

Claim Filing Instructions & Claim Form

Claim Filing Instructions & Claim Form Claim Filing Instructions & Claim Form Please follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the IMG Customer Service Department

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Submit via email Personal Accident and Sickness Claim Form Thank you for notifying us of your claim - Issue of this form is not an admission of liability PLEASE ENSURE You fully complete every question

More information

Group Journey Injury Insurance

Group Journey Injury Insurance Group Journey Injury Insurance Claim form All relevant sections are to be answered in full. Please print your answers. Zurich does not admit liability by the issue of this form. It is issued to enable

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: AN A038364 PAD Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TRIATHLON AUSTRALIA V-Insurance Group Pty Ltd Level 28, Angel Place, 123 Pitt Street, SYDNEY

More information

Personal Accident Insurance Accident Claim Form

Personal Accident Insurance Accident Claim Form Claimant & Accident Details Name of Birth Address Telephone Number Email Occupation Self-Employed Description of Working Duties If yes, will your business cease to operate during this incapacity of Accident

More information

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

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

More information

Inpatriate Medical Expenses Claim Form

Inpatriate Medical Expenses Claim Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 027

More information

Travel Insurance Claim Form

Travel Insurance Claim Form Jetstar Travel Travel Insurance Insurance Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for

More information

Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140

Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140 Accident Insurance Claim Form Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140 Employer /Group / Bank group: Full policy Number with Prefix : Full

More information

Equity accident claim form

Equity accident claim form In the event of an insured accident, you must return this competed claim form to Equity as soon as possible. Equity s address is Guild House, Upper St Martins Lane, London, WC2H 9EG. IMPORTANT: claims

More information

ACCIDENT CASH PLAN- HOSPITALISATION CLAIM FORM

ACCIDENT CASH PLAN- HOSPITALISATION CLAIM FORM ACCIDENT CASH PLAN- HOSPITALISATION CLAIM FORM Please provide as much information as possible when completing this form. If you are unable to fit your answers into the spaces below, please continue on

More information

SPORTS PERSONAL ACCIDENT AND SICKNESS CLAIM FORM

SPORTS PERSONAL ACCIDENT AND SICKNESS CLAIM FORM SPORTS PERSONAL ACCIDENT AND SICKNESS CLAIM FORM THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY Please Ensure: You fully complete every question before your doctor completes his statement. Failure

More information

HDFC Life New Immediate Annuity Plan

HDFC Life New Immediate Annuity Plan VER - 2 HDFC Life New Immediate Annuity Plan Guidelines for filling up the form This form is to be filled by the Proposer himself in BLOCK LETTERS in BLACK INK. Please tick boxes where appropriate. Please

More information

IMPORTANT INFORMATION: PLEASE READ CAREFULLY

IMPORTANT INFORMATION: PLEASE READ CAREFULLY BASKETBALL PERSONAL INJURY CLAIM FORM IMPORTANT INFORMATION: PLEASE READ CAREFULLY Dear Basketball member, Please find attached a claim form. Before lodging this form, please ensure all sections are fully

More information

In the event of a claim, contact our 24-hour helpline numbers

In the event of a claim, contact our 24-hour helpline numbers CLAIMS FORM FOR GROUP TRAVEL INSURANCE Claimant s Name : Claimant s Address: Phone No.(Mobile): Phone No.(Res) : E-mail ID: Policy Start Date : dd/mm/yyyy Policy End Date : dd/mm/yyyy In what capacity

More information

AIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM

AIA SINGAPORE ACCIDENT & HOSPITALISATION CLAIM FORM Important Notes: 1) AIA HealthShield Gold claims for Singaporeans and Permanent Residents must be submitted electronically via the medical institutions at the time of admission/discharge. 2) Please submit

More information

CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES

CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES Correct completion of these forms will assist us to make accurate and faster decisions

More information

1. Personal Statement

1. Personal Statement journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is

More information

Travel Claim Form. E mail Address: I.D. Card No. Age. Occupation Name of Employer. Telephone No. Home: Mobile: Business:

Travel Claim Form. E mail Address: I.D. Card No. Age. Occupation Name of Employer. Telephone No. Home: Mobile: Business: Return this form together with all necessary documents to: GasanMamo Insurance, Msida Road, Gzira GZR 1405 Malta For any queries please call 21 345 123 ext 5 Travel Claim Form Branch/Broker/TII Claim Number

More information

OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form

OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form CLAIM No:- For Office Use Only OSG Travel Claims are committed to providing a

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Willis Australia Limited ABN: 90 000 321 237 AFS License Number 240600 Office use only Policy Number: SUA/002395 Claim Number:. TABLE TENNIS AUSTRALIA PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TABLE

More information

Emergency Assistance Phone Numbers:

Emergency Assistance Phone Numbers: Thank you for purchasing the IMG OUTREACH Plan. This document includes tips for team leaders and travelers as well as resources for filing a successful claim. We highly recommend reviewing and printing

More information

PERSONAL INJURY INSURANCE CLAIM FORM. Basketball SA

PERSONAL INJURY INSURANCE CLAIM FORM. Basketball SA PERSONAL INJURY INSURANCE CLAIM FORM Basketball SA SPORTS PERSONAL ACCIDENT CLAIM FORM Dear Soccer NSW Futsal Member 1 Dear Basketball member, Please find attached a claim form. Before lodging this form,

More information

PERSONAL INJURY CLAIM FORM AUSTRALIAN CRICKET NATIONAL CLUB INSURANCE PROGRAM

PERSONAL INJURY CLAIM FORM AUSTRALIAN CRICKET NATIONAL CLUB INSURANCE PROGRAM To access a claim form please go to www.jltsport.com.au/cricketaustralia or call Echelon (formerly JLT Claims Management Services) on 1800 640 009 JLT Sport a division of Jardine Lloyd Thompson Pty Limited

More information

JetProtect Overseas Travel Claim Form

JetProtect Overseas Travel Claim Form JetProtect Overseas Travel Claim Form Claimant s Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Claimant s Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

More information

Aon s Student Accident Protection Plan School student accident claim form

Aon s Student Accident Protection Plan School student accident claim form Lutheran Church of Australia School Student Personal Accident Protection Plan 2015-2016 Claims Procedure and Summary of Cover (For full details of cover, please refer to the Policy wording) Claims Procedure

More information

JUDO FEDERATION OF AUSTRALIA

JUDO FEDERATION OF AUSTRALIA Office use only Policy Number: ANA043293PAD Claim Number: JUDO FEDERATION OF AUSTRALIA PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR : V-Insurance Group Pty Ltd Authorised Representative No. 432898 an

More information

Claims Procedure. Claim forms and blank Medical Practitioners Statements are available from your school or the LCA website, or you can contact -

Claims Procedure. Claim forms and blank Medical Practitioners Statements are available from your school or the LCA website, or you can contact - Lutheran Church of Australia School Student Personal Accident Protection Plan 2013-2014 Claims Procedure and Summary of Cover (For complete details, please refer to the Product Disclosure Statement and

More information

supplier claim form RAF 2

supplier claim form RAF 2 1 supplier details: Supplier name Telephone number Practice number (BHF/HPCSA) Facsimile number Tax reference number Cellular number Physical address Postal address How would you like us to contact you?

More information

STUDENT ACCIDENT INSURANCE CLAIM FORM FEDERATION OF PARENTS & CITIZENS ASSOCIATIONS OF NEW SOUTH WALES

STUDENT ACCIDENT INSURANCE CLAIM FORM FEDERATION OF PARENTS & CITIZENS ASSOCIATIONS OF NEW SOUTH WALES STUDENT ACCIDENT INSURANCE CLAIM FORM FEDERATION OF PARENTS & CITIZENS ASSOCIATIONS OF NEW SOUTH WALES The issue or acceptance of this form is not construed as an admission of liability on the part of

More information

Expiry Date. If you have selected Cheque please nominate payee

Expiry Date. If you have selected Cheque please nominate payee TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Please answer all questions and provide all relevant documentation to avoid delays with your We are unable to process

More information

PERSONAL ACCIDENT INSURANCE CLAIM FORM AND PROCEDURE

PERSONAL ACCIDENT INSURANCE CLAIM FORM AND PROCEDURE PERSONAL ACCIDENT INSURANCE CLAIM FORM AND PROCEDURE In order that your claim may be dealt with as quickly as possible, please ensure that you tick that you have addressed all of the items below.. If you

More information

Singapore Airlines Claim Form

Singapore Airlines Claim Form Singapore Airlines Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for us to return your claim

More information

CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED

CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED C H U B B CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED A.B.N. 69 003 710 647 Sydney: Level 36, Tower Building Australia Square, 264-278 George Street, Sydney, NSW, 2000 Australia Telephone : 61-2-9273

More information

Do not complete this claim form unless you have been or will be off work for longer than your selected waiting period (30, 60 or 90 days)

Do not complete this claim form unless you have been or will be off work for longer than your selected waiting period (30, 60 or 90 days) Income Protection Injury & Sickness Insurance Claim For further information contact Australian Income Protection Pty Ltd on: Phone: 1300 559 362 Do not complete this claim form unless you have been or

More information

Macquarie Life Total Permanent Disability (TPD): Claimant s Statement

Macquarie Life Total Permanent Disability (TPD): Claimant s Statement Macquarie Life Total Permanent Disability (TPD): Claimant s ment Filling in this statement Please complete all sections, use black ink and mark boxes like this with an X. 1 May we disclose information

More information

First Notice of Claim for Illness or Injury

First Notice of Claim for Illness or Injury First Notice of Claim for Illness or Injury How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents

More information

How To Get A Netball Insurance Policy In Netball V Victoria

How To Get A Netball Insurance Policy In Netball V Victoria Office use only Policy Number: SUA/003700 Claim Number:. PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR NETBALL VICTORIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised representative

More information

Your People, Protected. Sports group Personal Accident Claim Form

Your People, Protected. Sports group Personal Accident Claim Form Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this

More information

How To Claim For An Accident Or Injury In Netball

How To Claim For An Accident Or Injury In Netball Office use only Policy Number: SUA/003700 Claim Number:. PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised representative of Willis

More information

Phillips House 12 Church Street Harwich Essex CO12 3DS Phone: 01255 553039 Fax: 01255 240560 Email: hq@theisu.co.uk

Phillips House 12 Church Street Harwich Essex CO12 3DS Phone: 01255 553039 Fax: 01255 240560 Email: hq@theisu.co.uk Personal Accident Claim Phillips House 12 Church Street Harwich Essex CO12 3DS Phone: 01255 553039 Fax: 01255 240560 Email: hq@theisu.co.uk 1 What Should I do Now? Please ask your doctor to complete the

More information

ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM

ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM Important te: Please note that, under the policy terms and condition, the policy may be void if any information provided in this claim form are made knowingly

More information