Complete and Submit this form to the Bajaj Allainz Claim Office to request for a Daily Hospital Cash Allowance according to your Policy guidelines.
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Bajaj Allianz General Insurance Company Limited
Head Office : GE Plaza, Airport Road, Yerawada, Pune – 411 006
HOSPITAL CASH DAILY ALLOWANCE POLICYHOSPITAL CASH DAILY ALLOWANCE POLICY
Claim F
Claim FClaim Form
ormormPLEASE ANSWER EVERY QUESTION AND FULLY
The issue or acceptance of this form is not to be construed as admission of liability on the part of the CompanyRegional / Branch Office Code
Broker / Agent Name & code CodeInsured Details
Name of the Insured
Client IDDetails of Insured Person(s) in respect of whom claim is made
1. Name of the Insured Person,
Age
2. Relationship with the Insured
3. Nature of illness/disease
contracted or injury suffered
4. Date of injury sustained or
disease/illness first detected
5. Name & address of the
attending Medical Practitioner
6. Name & address of the
Hospital/Nursing Home where
treatment is taken/being taken
7. a) Date and time of
admission in the Hospital
b) Date and time of discharge
from the Hospital
Please furnish proof of Hospitalisation like
Discharge Summary from the Hospital,
Certificate from the attending Medical
Practitioner regarding nature illness/disease,
injury necessitating hospitalisation.
8. Do you have any other
insurance cover covering
Hospital Cash Allowance ?
If Yes, give details.
Yes No
I/We hereby declare that the foregoing statements are true in all respects and that I/We have not attempted to conceal from the
company anything with which it ought to be made acquainted and also that if I/We have made or in any further declaration the Company may
require shall make any false or fraudulent statement or any suppression, concealment or untrue averment whatever, the Policy shall be void and
my/our right to compensation forfeited and am/are willing if required, to make a statutory Declaration before a Justice of the Peace of the truth of
the whole of the foregoing statement or any other statement I/We may make in connection with this claim.Signature of the Insured
(In case of minor children, the Insured may sign)
Date DateAddress