For a claim of a Critical illness you need to fill this form and submit it to the Bajaj Allianz claim office. This form is only valid if your current Bajaj Allianz Health Insurance policy covers Critical Illness.
Regd. Office: Bombay Pune Road, Akrudi, Pune 411 035 & Head Office: GESCO Plaza, Airport Road, Yerawada, Pune 411 006
CRITICAL ILLNESS COVER
Claimant’s Statement
Claim No (TO BE GIVEN BY BAGICL)
1 Name of the Insured :
2 Policy Number :
3 Residential Address :
4 Home telephone number :
Business telephone number
5 Present completed age :
6 Occupation at the onset of your illness :
Please describe activities/duties of your job
7 Please give details of extent and nature of
your current illness
:
8 Date on which you first consulted a doctor
for this illness
:
9 Have you previously from or received any
treatment for a related illness? Yes/No if
yes, give complete details
:
10 Please give details of the treatment you
have received including dates of out patient
or inpatient treatment
:
11 Have any of your blood relatives suffered
from similar or related illness? If yes, give
details of when it was initially diagnosed
:
12 Do you smoke Cigarettes? Yes /No :
13 Please give the name, address and phone
number of your family physician
:
14 Please give names, addresses and telephone
numbers of all physicians who have treated
you and of all hospitals at which you have
been treated for this illness (include dates
attended) (format B elow)
:Bajaj Allianz General Insurance Company Ltd.
Name (Specialty) Address
Telephone NumbersIn support of the above claim, I enclose following documents (Please indicate by tick mark)
1.
Discharge certificate/Discharge card from the Hospital
2.
Specialist’s certificate confirming the diagnosis with supporting pathological, imaging or any other
reports
3.
Surgeon’s certificate stating nature of operation performed with detailed operative notes
4.
Details of the anesthesiologist’s report with pre operative, operative and post operative comments
I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or
shall make any false or untrue statement suppression or concealment my right to claim reimbursement of
the said expenses shall be absolutely forfeited. I further declare that in respect of the above treatment no
benefits are admissible under any other Medical Scheme of insurance. I consent and authorize the
Bajaj Allianz General Insurance Company or their representatives to seek medical inform ation from
any Hospital/Medical Practitioner who has at any time attended concerning the claim.Date :
Signature of the Claimant
Bajaj Allianz General Insurance Company Ltd.