Domiciliary Claim Form Canara Bank PDF
Domiciliary Claim Form Canara Bank PDF
Domiciliary Claim Form Canara Bank PDF
i) Policy No.
ii) Employee ID of the Primary Insured
iii). MDINDIA Health Card No MDI5-00
iv) Name of the Primary Insured
B) Details of Patient
i) Name of Patient
ii) Gender
i) Nature of illness/diagnosis
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ii. Prescription & certificate of illness – original/ photocopy duly attested (Please tick the relevant field).
If photocopy given reasons for the same)
iii. Original bills/Paid Receipt of consultation fees.
iv. Original pharmacy bills of medicines purchased (Tax invoice with GST No Printed)
v. Original bills of Lab test done
vi. Reports of the latest pathological investigation confirming diagnosis
vii. Self-Declaration form
viii. Others.(specify)
Total
H) Bank Account Details of Primary Insured (Not required in cases of Serving Employees)
I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge
and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect
to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited, I also consent &
authorize TPA/ Insurance Company, to seek necessary medical information / documents from any hospital / Medical
Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included
all the bills/ receipts for the purpose of this claim & that I will not be making any supplementary claim except the
pre/post-hospitalization claim, if any.
Date
DD / MM/ YYYY Place: Signature of the Primary Insured
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