RGI Covid-19

Policy No	Policy End Date	UHID Number	Policy Status	Insured Name	Action
{{data.PolicyNo}}	{{data.PolicyEndDate}}	{{data.UHID}}	{{data.PolicyStatus}}	{{data.InsuredName}}	Intimate Claim

DETAILS OF INSURED

POLICY NO

MASTER POLICY NO

INSURED NAME

GENDER

DATE OF BIRTH

YEAR

MONTH

ADDRESS

STATE

CITY

PINCODE

MOBILE NO

EMAIL ID

PREFERRED COMMUNICATION DETAILS [ OTP will be send on below details ]

MOBILE NO

EMAIL ID

TYPE OF LOSS

Diagnosis Cover

Quarantine Cover

Loss Of Pay

Loss Of Employment

Travel Exclusion Cover

LAB NAME

LAB ENTITY

Government Private

TEST DATE

LAB STATE

LAB CITY

LAB ADDRESS

QUARANTINE TYPE

Home Institutional

QUARANTINE DATE

QUARANTINE STATE

QUARANTINE CITY

QUARANTINE ADDRESS

DETAILS OF HOSPITALISATION

IS HOSPITALIZATION ?

Yes No

NAME OF HOSPITAL

HOSPITAL ADDRESS

DATE OF ADMISSION

TIME

DATE OF DISCHARGE

TIME

NO.OF DAYS OF LEAVE DUE TO LOSS OF PAY(0 to 30)

UNEMPLOYMENT NO.OF MONTHS(0 to 3)

ADDITIONAL INFORMATION/DETAILS

DETAILS OF CLAIMANT BANK ACCOUNT

PAN NO

PAYMENT MODE

ACCOUNT NUMBER

IFSC CODE

BANK NAME

BRANCH NAME

CHEQUE/DD PAYABLE DETAILS

Document Check List

SPECIAL DECLARATION

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.

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