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Policy No Policy End Date UHID Number Policy Status Insured Name Action
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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
LAB NAME
LAB ENTITY
TEST DATE
LAB STATE
LAB CITY
LAB ADDRESS
QUARANTINE TYPE
QUARANTINE DATE
QUARANTINE STATE
QUARANTINE CITY
QUARANTINE ADDRESS
DETAILS OF HOSPITALISATION
IS HOSPITALIZATION ?
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
SPECIAL DECLARATION
Document Name File Name Delete
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