THE ORIENTAL INSURANCE COMPANY LIMITED
Regd.Office : Oriental House, P.B.No.7037,A-25/27, Asaf Ali Road, New Delhi- 110002

CLAIM FORM FOR CLAIM UNDER NAGRIK SURAKSHA POLICY

The Branch/Divisional Manager CLAIM No._____________
The Oriental Insurrance company Ltd.,
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: From_________To
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/
NURSING HOME.
9.DETAILS OF THE AMOUNT CLAIMED : (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. 2. 3. 4.
S C H E D U L E
Name of the insured Sum insured
Age
(years) Personal
Accident
Section
(Rupees)
80%
Hospitalisation
Section
( Rupees )
20%
Total Sum
insured
(Rupees)
100%
Cumulative
Bonus
Assignee: - In case of Death claim payable to : ______________________
Premium Rate (Rs. %o) Rs.______
Net premium Rs.______
Staff Discount Rs.______
Family Package Discount Rs.______
Service Tax Rs.______
Group Discount Rs.______
No claim Bonus/Loading Rs.______
Total Premium Rs.______
___________________________________________________________________________
Collection No. for and on behalf of
Collection Dt. The Oriental Insurance Company Limited
Authorised Signatory
__________________________________________________________________________