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Free Bajaj Allianz Health Insurance Claim Form - PDF Form Download

Bajaj Allianz Health Insurance Claim Form Overall rating: ☆☆☆☆☆ 0 based on 0 reviews
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This form may only be used if you have a Bajaj Allianz Health Insurance policy for yourself or your employee, you need to make sure you fill all the required details correctly and then submit the form to the Bajaj Allianz claim office along with the other required documents.


HEALTH INSURANCE CLAIM FORM

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 DD / MM/ YYYY Policy End Date DD/MM/YYYY
Bajaj Allianz Claimant ID Card No: ___________________________________________________________________
Corporate Name : __________________________________________________________ (Only for Group Policies)
PERSONAL DETAILS OF EMPLOYEE/PROPOSER
1 Name of the Employee/Individual
2 Employee No (if any)
3 Date of Joining the Policy (DOJ) DD/MM/YYYY
4 E-Mail address of the Employee/Individual
5 Contact No (Mobile No)

CLAIMANT / PATIENT DETAILS
1 Name of the Patient:
2 Relationship with the Employee / Proposer Self / Spouse/ Child / Parent / Others – Please Specify
3 Date of Birth of Claimant DD/MM/YYYY Age : ______
4 Gender
5 Residential Address

CLAIM DETAILS
Total Claimed Amount: Rs.
Claimed Amount in Words: Rupees ____________________________________________________________________
1.Provisional Diagnosis / Nature of Disease
_____________________________________________
2. Date of Admission : DD_/_MM_/_YYYY
3. Date of Discharge : DD_/_MM_/_YYYY
Enclosure Check List :
1. Discharge Summary containing all relevant details.
2. All Bills and their Receipts.
3. All Reports & prescriptions
5. Certificate regarding Diagnosis

PLEASE ENCLOSE A PHOTOCOPY OF THE BAJAJ ALLIANZ HEALTH ID CARD

Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required
for each claim
HEALTH INSURANCE CLAIM FORM
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: DD_/_MM_/_YYYY
Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required
for each claim
Mandate
Form
for
Electronic
Transfer
of
Claim
Payments
To,BajajAllianzGeneralInsuranceCompanyLtdOfficeCode&Name:
I-trackNumber:
Partner
ID
(To
be
filled
by
Office)
:

Full
Name:
Shri
/
Smt
/
Kum
/
M/s
_______________________________________
(As
appears
in
your
bank
account)
Full
Address:
__________________________________________________________
__
PIN
Code:
________________
Contact
/
Mobile
No:
__________
___Email
ID:________________________________________
Particulars
of
bank:
BankName:
Branch
Name
&
Address:
BranchTelephoneNo&ContactNo:
BranchMICRCode
Branch
IFSC
Code
for
NEFT
Branch
IFSC
Code
for
RTGS
NameoftheAccountHolder:
(AsperBankAccount)
Account
Type
Savings
Current
Cash
Credit
Account
No.
(as
appearing
in
the
cheque
book)
I/we
have
read
the
declarations
/
conditions
mentioned
overleaf.
Place:
____________
Date:
_____________
_______________________
(Beneficiary’s
Signature)
(Please
attach
copy
of
a
cancelled
blank
cheque
of
your
bank
for
ensuring
accuracy
of
name
of
the
bank,
branch
name,
Account
number
and
IFSC
code.
If
name
of
the
payee
is
not
printed
on
the
cheque
leaf
please
attach
copy
of
the
first
page
of
the
bank
passbook
also
)

DECLARATION

I
/
We
hereby
declare
that
the
particulars
given
above
are
correct
and
complete
and
no
blanks
have
been
left.
If
the
transaction
is
delayed
or
not
effected
at
all
for
reason
of
incomplete
or
incorrect
information
I
/
we
would
not
hold
Bajaj
Allianz
General
Insurance
Company
Limited
responsible.

I
/
We
undertake
to
revoke
the
instruction
for
NEFT
in
the
event
of
the
business
relationship
expiring
and
or
being
‘terminated’
and
further
hereby
specifically
authorize
Bajaj
Allianz
General
Insurance
Company
Limited,
to
do
so,
for
me
and
on
my
behalf,
in
case
the
revocation
communication
is
not
received
from
me
within
seven
days
of
expiry
and
or
being
termination
of
relationship.

I
/
We
further
undertake
to
refund,
at
any
time,
any
excess
amount
whether
demanded
by
Bajaj
Allianz
General
Insurance
Company
Limited
or
not,
which
has
been
credited
to
my
account
[due
to
any
reason]
by
Bajaj
Allianz
General
Insurance
Company
Limited,
in
excess
of
(i)
the
amount
due
to
me,
or
(ii)
in
excess
of
amount
for
which
I
gave
mandate,
and
or
(iii)
agreed
rent/license
fees/compensation/refundable
security
deposit/Commission/Claim/Refund/
Any
other
payment.

I
/
We
agree
that
the
payment
will
be
endeavoured
to
be
credited
starting
from
the
date
of
next
payment
cycle
and
unless
the
Mandate
is
revoked
by
me/us
issuance
of
relevant
credit
instruction
for
electronic
payment
from
Bajaj
Allianz
General
Insurance
Company
Limited
into
the
aforesaid
account
will
be
valid
discharge
to
Bajaj
Allianz
General
Insurance
Company
Limited
for
having
paid
(i)
the
amount
due
to
me,
or
(ii)
in
excess
of
amount
for
which
I
gave
mandate,
and
or
(iii)
agreed
rent/license
fees/compensation/refundable
security
deposit/
Commission/Claim/Refund/
Any
other
payment.

I
/
We
further
confirm
that
we
understand
this
mode
as
a
method
of
payment
introduced
by
Reserve
Bank
of
India,
which
provides
us
an
option
to
receive
the
amount
and
or
to
collect
our
payments
by
electronic
payment
mode
directly
through
my/our
bank
accounts.

I
/
We
further
confirm
that
I/we
understand,
Bajaj
Allianz
General
Insurance
Company
Limited,
shall
make
electronic
payment
to
my
account
by
issuing
the
Payment
instruction
electronically
through
its
banker
to
the
Clearing
Authority
and
the
Clearing
Authority
would
ensure
credit
to
my/our
specified
bank
account
provided
hereinabove.

I
/
We
further
undertake
to
inform
Bajaj
Allianz
General
Insurance
Company
Limited
with
an
advance
notice
of
6
weeks,
to
withdraw
from
this
mode
of
electronic
payment.

I
/
We
further
confirm
that
Bajaj
Allianz
General
Insurance
Company
Limited
will
have,
at
its
sole
discretion,
the
right
to
return
back
to
the
option
of
paying
to
me/us
by
way
of
cheque
if
there
are
more
than
2
consecutive
failures
in
remittances
for
no
fault
on
the
side
of
Bajaj
Allianz
General
Insurance
Company
Limited.

After
Bajaj
Allianz
General
Insurance
Company
Limited
issuing
the
Payment
instruction
electronically
through
its
banker,
for
whatever
reasons,
if
I/we
do
not
get
the
credit
to
my/our
account,
then
same
shall
neither
constitute
the
default
in
(i)
Payment
of
amount
requested
by
me,
or
(ii)
Payment
of
amount
due
to
me/us,
or
(iii)
Payment
of
agreed
rent/license
fees/compensation/refundable
security
deposit/
commission/claim/
Refund/Any
other
payment
by
Bajaj
Allianz
General
Insurance
Company
Limited
nor
constitute
default
of
any
terms
and
conditions
of
any
agreement/MOU/
Claim/Refund/Other
contract
and
or
Lease
agreement/Leave
and
license
agreement
with
me/us.

Bajaj Allianz Health Insurance Claim Form

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