FORM 2: CLAIM FORM IFFCO TOKIO GENERAL INSURANCE COMPANY LIMITED CLAIM FORM - PART A (TO BE FILLED IN BY INSURED)

INSURANCE DETAILS Policy No Company/ TPA ID No Address of Proposer (Primary Insured) Name of Claimant Relation to proposer Address Gender Telephone No E-mail ID, if any Insurance History Date of commencement of first Insurance for the person Y/N Male / Female Occupation Mobile No Date of Birth Age SNo/ Certificate No: Name of Proposer

Are you presently covered with any other Mediclaim / Health Insurance? If Y, give details - Company / Policy No / Sum Insured (Attach Policy copies) Primary Insured's Bank Account particulars Account Number Branch PAN No. Bank Name IFSC Code HOSPITALIZATION DETAILS Name of the Hospital where admitted Room Type-Day care / Single / Twin sharing etc Past Hospitalisation Y/N Month and Yr Details DIAGNOSIS:

Hospitallisation due to: Illness / Injury / Maternity Date of Injury / Disease first detected / LMP If injury, how it occurred If injury, whether Medico legal Is claim is for Domiciliary Hospitalisation? Y/N

If MLC, reported to police? Y/N (If Y, provide details in annexure

Y/N (Enclose MLC /FIR)

EXPENSES AND BILLING DETAILS Pre-hospitalisation Expenses Post-hospitalisation Expenses Ambulance Charges Rs. Rs. Rs. Hospitalisation Expenses Health-Check up Cost Others Rs. Rs. Rs.

Details of Lumpsum / cash benefit claimed: Hospital Daily Cash Convalescence: Surgical Cash Pre / Post hosp lumpsum benefit: Critical Illness benefit Others

Details of bills enclosed (attach separate sheet, if space inadequate) Sl. Bill No Date Issued By Towards Amount

Details of Claim Documents submitted - CHECK LIST Claim Form Duly signed Copy of the claim intimation Hospital Discharge Summary Operation Theatre Notes Hospital Main Bill Hospital Break-up Bill Hospital Bill Payment Receipt Doctor\s Prescriptions Y Y Y Y Y Y Y Y | N | N | N | N | N | N | N | N Pre-hosp Bills: _____ Nos Post-hosp Bills: _____ Nos Investigation Reports Doctor request for investigation ECG Pharmacy Bills MLC Report & Police FIR Any other, please specify Y Y Y Y Y Y Y Y N N N N N N N N

Date:

Signature of the Primary Insured / Claimant

Contd

CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL Name of the Hospital Type of Hospital Network Non Network Hosp ID

In case of non network , please provide below details

Address of the Hospital with Pin Code

Telephone No Number of Inpatient beds Other Facilities available in the hospital ICU Details of the patient admitted Name of the patient Gender Date of Admission Date of Discharge Ailment Diagnosed (Primary) ICD 10-CM Code Details of Procedure/s done ICD 10 PCS Code Type of Admission Date of delivery if Maternity maternity 8. Is the treatment for an injury? If, Y, details. Was it self inflicted? If MLC, notified to police? to police If MLC not notified, give reasons Y/N Y/N Proc 1 Emergency Primary Diagnosis | Y/N

Registration no. PAN OT Others Y/N

IP Registration Number Age Time of Admission Time of Discharge

Additional Diagnosis

Comorbidities

Proc 2 Planned Gravida Status

Proc 3 Day-care | Maternity

Whether RTA MLC / FIR No.

Y/N

Was the Injury / disease caused due to Substance abuse / Alcohol consumption If Y, whether any test was conducted to establish this? If Y, please attach Report Is present ailment a complication of Pre-existing disease pre-existing disease Y/N

Y/N Y/N

Contd

If Y, specify details Whether Pre-authorisation obtained - Y/N If authorisation by network hospital not obtained, reason? reason Name of Treating Doctor doctor Mobile No If Y, Pre Auth Number

Registration No state code Qualification

13. Claim Documents submitted (CHECK LIST) Registeration Certificate as Medical Establishment if NOT APPLICABLE use Form 3(attached) Investigation Reports (Including CT / MRI / USG / HPE) Doctor's Reference Slip for investigation ECG Pharmacy Bills MLC Report & Police FIR Any other, please specify

Claim Form Duly signed

Original Pre-authorisation request Copy of the preauthorisation approval letter Hospital Discharge Summary Operation Theatre Notes Hospital Main Bill Hospital Break-up Bill

Date:

Signature of the Primary Insured / Claimant