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Insureatclick. com-Broker Loyal Insurance Brokers Ltd. CLAIM FORM FOR CLAIM UNDER NAGRIK SURAKSHA POLICY The Branch/Divisional Manager CLAIM No. The Oriental Insurrance company Ltd. THE ORIENTAL INSURANCE COMPANY LIMITED Regd. Office Oriental House P. B. No*7037 A-25/27 Asaf Ali Road New Delhi- 110002 Downloaded from www. I hereunder give the details of the accident and the subsequent medical treatment taken at the hospital/nursing home. 1. NAME OF THE CLAIMANT 2. NAME OF THE INSURED PERSON 3. PRESENT RESIDEDENTIALADDRESS OF THE INSURED 4. DETAILS OF THE POLICY UNDER a Policy No WHICH CLAIM IS PREFERRED b Period FromTo 5. BRIEF DETAILS OF THE ACCIDEDNT a Date b Time c Place d Details of occurrence please attach separate sheet 6. DETAILS OF DISABILITY/ DEATH INCASE OF DEATH ORIGINAL DEATH CERTIFICATE FROM THE APPROPRIATE AUTHORITY MUST BE ATTACHED 7. NAME AND ADDRESS OF THE HOSPITAL/ NURSING HOME WHERE THE INSURED HAD UNDERGONE THE TREATMENT. 8. DATE AND TIME OF ADMISSION AND DISCHARGE FROM THE HOSPITAL/ a Rs. under PA Section of the policy b Rs. under hospitalization section of the Policy I FURTHER CONFIRM AND DECLARE THAT THE INFORMATION FURNISHED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND IF AT ANY STAGE IT IS FOUND THAT ANY OF THE INFORMATION FURNISHED BY ME ABOVE IS INCORRECT THE CLAIM PREFERRED ABOVE MAY BE FORFEITED BY THE COMPANY. DATE PLACE SIGNATURE OF THE CLAIMANT NB 1. PLEASE NOTE THAT ISSUANCE OF THIS CLAIM FORM DOES NOT AMOUNT TO ADMISSION OF THE LIABILITY BY THE COMPANY. 2. ALLTHE ORIGINAL DOCUMENTS LIKE CASH MEMOS BILLS ETC. SHOULD BE ENCLOSED IN SUPPORT OF CLAIM. LIST OF ENCLOSURES 1. S C H E D U L E Name of the insured Sum insured Personal Hospitalisation Accident Section Rupees Age years Total Sum Cumulative Bonus Assignee - In case of Death claim payable to Premium Rate Rs. o Staff Discount Net premium Service Tax Family Package Discount Rs. Group Discount No claim Bonus/Loading Total Premium Rs. I hereunder give the details of the accident and the subsequent medical treatment taken at the hospital/nursing home. 1. NAME OF THE CLAIMANT 2. NAME OF THE INSURED PERSON 3. PRESENT RESIDEDENTIALADDRESS OF THE INSURED 4. 1. NAME OF THE CLAIMANT 2. NAME OF THE INSURED PERSON 3. PRESENT RESIDEDENTIALADDRESS OF THE INSURED 4. DETAILS OF THE POLICY UNDER a Policy No WHICH CLAIM IS PREFERRED b Period FromTo 5. BRIEF DETAILS OF THE ACCIDEDNT a Date b Time c Place d Details of occurrence please attach separate sheet 6. DETAILS OF THE POLICY UNDER a Policy No WHICH CLAIM IS PREFERRED b Period FromTo 5. BRIEF DETAILS OF THE ACCIDEDNT a Date b Time c Place d Details of occurrence please attach separate sheet 6. DETAILS OF DISABILITY/ DEATH INCASE OF DEATH ORIGINAL DEATH CERTIFICATE FROM THE APPROPRIATE AUTHORITY MUST BE ATTACHED 7. DETAILS OF DISABILITY/ DEATH INCASE OF DEATH ORIGINAL DEATH CERTIFICATE FROM THE APPROPRIATE AUTHORITY MUST BE ATTACHED 7. NAME AND ADDRESS OF THE HOSPITAL/ NURSING HOME WHERE THE INSURED HAD UNDERGONE THE TREATMENT. 8. DATE AND TIME OF ADMISSION AND DISCHARGE FROM THE HOSPITAL/ a Rs.

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