The New India Assurance Company Limited
Registered & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai - 400 001.
OPD CLAIM FORM
Issuance of this form does not amount to admission of any liability of under the policy on the part of the Insurers
Please give the following information correctly and completely to enable us process your claim promptly.
All dates to be entered as Date / Month / Year
Type of Claim: - Domiciliary Dental Vision Health-check up
1. Corporate Name / Entity Name :
2. Policy Number (in Full) : 14010034210400000005
3. Employee Number : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
4. Name of the Employee : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ ____
5. Employee Code / Cirlce : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
6. Details of the Patient
Name Of Patient :
DOB : : _____________________________
Relationship : Employee Spouse Child Parents / In laws
7. Nature of Disease contracted/Ailment
Suffered or injury sustained (Optional) : ________________________________________
8. Date on which injury was sustained/Disease
Or ailment first detected (Optional) : ________________________________________
9. Name and Address of the attending
Medical Practitioner : ________________________________________
Location : ________________________________________
Details of Expenses ( Attach Supportings) No of Bills Total
1. Consultation Fees
2. Medicines
3. Tests/X-rays/ECG etc.
4. Visiting fees
5. Others
Grand Total :Rs _________________________
1
DECLARATION
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 of any fact, 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 availed or claimed under any other Medical Scheme or Insurance.
I ALSO CONSENT AND AUTHORISE THE NEW INDIA ASSURANCE COMPANY LIMITED & THIRD
PARTY ADMINISTRATOR TO SEEK MEDICAL INFORMATION FROM ANY HOSPITAL / MEDICAL
PRACTITIONER WHO HAS AT ANY TIME ATTENDED ON ME.
I also authorize TPA to receive payment from the insurance company as reimbursement of hospital bills
incurred on my / the insured person’s treatment.
Date: ( DD-MMM-YY) :
Place:
Signature of the Claimant / Employee
