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Free Bajaj Allianz Extra Care Claim Form - PDF Form Download

Bajaj Allianz Extra Care Claim Form Overall rating: ☆☆☆☆☆ 0 based on 0 reviews
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Use this claim form only if you have a Bajaj Allianz Extra Care Health insurance policy. For more details about this policy lookup at the Bajaj Allianz website.


Bajaj Allianz General Insurance Company Limited
Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune – 411 006
1 Name of the Individual
2 Email address of the Employee / individual
3 Contact No. (Mobile No.)
1 Name of the Patient:
2 Relationship with the Proposer Self / Spouse / Child
3 Date of Birth of Claimant Age :
4 Gender
5 Residential Address
CLAIM DETAILS
IN CASE OF HOSPITALISATION CLAIM

Extra Care Claim Form
Total Claimed Amount Rs. Deductible Amount
Claimed Amount in Words : Rupees
1 Provisional Diagnosis / Nature of Disease
_______________________________________________
2 Date of Admission : ________________________________
3 Date of Discharge : ________________________________
Enclosure Check List (originals) * :
1 Discharge Summary containing all relevant details.
2 All Bills and their Receipts.
3 All Reports & prescriptions
4 Certificate regarding Diagnosis
ALL FIELDS IN THIS FORM ARE MANDATORY AND THE CLAIM WILL BE NOT BE PROCESSED IF ANY OF THE DETAILS ARE MISSING
Claim Number (For BAGIC Use Only) ___________________________________
POLICY DETAILS
Policy No : OG – ___________________________________________________________________________________________________
Policy Start Date : ______________________________________ Policy End Date : _____________________________________________
Bajaj Allianz Claimant ID Card No: ____________________________________________________________________________________
PERSONAL DETAILS OF PROPOSER
CLAIMANT / PATIENT DETAILS
PLEASE ENCLOSE A PHOTOCOPY OF THE BAJAJ ALLIANZ HEALTH ID CARD
* In case the originals are required by the primary insurer ,we would return the original documents to the primary insurer after stamping the
documents for the amount we have settled under the policy .
Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required for each claim

CONSENT REQUIREMENT FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT
Dear Sir / Madam,
In order to proceed with your claim, Bajaj Allianz General Insurance may need to see your health records. Our doctors may need to review all your
medical records including admission notes, treatment sheets, indoor case papers, investigation reports, prescriptions and all other documents
present in the hospital case file. This will facilitate faster processing and adjudication of your claim. You are requested to sign the authorization
form below to allow Bajaj Allianz General Insurance access to the above medical records.
AUTHORIZATION FORM FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT
Medical Director
Dear Sir / Madam,
I _______________________________________________________________ (Name of Patient) was admitted in your hospital from
__________________________ to ___________________________. I am insured with Bajaj Allianz General Insurance as per the policy details
given overleaf.
I hereby authorize Bajaj Allianz General Insurance or any agency / individual authorized by them to obtain copies or review in person all my
medical records including but not limited to admission notes, treatment sheets, indoor case papers, investigation reports, prescriptions and all
other documents present in the hospital case file. Details related to my past hospitalisations in your hospital can also be provided / shown to Bajaj
Allianz or its authorized representatives.
Verification of the above consent can be obtained from me at _____________________________________
(Patient / Relative Phone Number) _______________________________________________
Name of Patient / Relative: ______________________________________________________
Relationship with Patient: ______________________________________________________
Signature of Patient / Relative: __________________________________________________
Date: __________________________
Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required for each claim
BJAZ/CF/Extra Care / 01/2010

Bajaj Allianz Extra Care Claim Form

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