Medical Claim Form

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Claim No. :
Policy No. :
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Name of Insured :
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Age/Sex : 
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Relation : 
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Name of Employee :
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Designation :
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Ticket No./Clock No. :
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1. Nature of Illness :
As per attached xerox.
2. Date of Illness/Accident :
{{dateOfIllness}}
3. Time & Place of Accident :
4. Prescribed by Hospital Medical Officer/Hospital/Panel Doctor :
   Yes   ✓   No
5. Details of Expenses 
Hospital Charge :
Rs. 
Medicines :
Rs. 
Laboratory Charges :
Rs. 
X-Ray Charges :
Rs. 
Doctor's Fees :
Rs. 
Total :
Rs. 
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Total No. of Bills & Prescription attached
:
Signature of Claimant :
Date :
{{dateToday}}
1. Verified all the documents and Recommendation for payment of medical claim.
Signature of Doctor
Signature of H.R. Executive
For Office User Only
Claim Scrutiny
Checked and Forwarded for Approval of Nrs.
Approved for Nrs.
Deduction on account of 12.5% Copayment:
Signature
Competent Authority