CLAIM FORM - The New India Assurance Co. Ltd.

THE NEW INDIA ASSURANCE CO. LTD.,Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001.UNIVERSAL HEALTH INSURANCE POLICY for APL FAMILIESCLAIM FORM(Please fill up the relevant sections)Policy issuingofficeName of the insured:Address of the insured:Policy Number:Period of Insurance:SECTION IA) HOSPITALISATION EXPENSESName of the patient: Age: Sex:Nature of Illness:Name of HospitalDate of Admission:Name of treating doctorDate of Discharge:Amount:B) DISABILITY COMPENSATION:Amount:Date of Admission:Amount:Date of Discharge:1

*Please attach discharge card, bills, cash memos, diagnostic reports etc.SECTION IIPERSONAL ACCIDENT COVER TO EARNING HEAD OF THEFAMILYName of the insured:SexAge:Date of accident:Date of death:Details of accident in brief:Date of intimation to Police:Please submit FIR & Post Mortem Report____________________________________________________________I declare that to the best of my knowledge all particulars contained in formare trueDate:Signature of the Claimant/NomineePlace:______________________________________________________________________For Office Use Only:SECTION IAmount:A) Claim under Hospitalisation:B) Claim for Disability CompensationC) Claim under Maternity BenefitSECTION IIPA CLAIM FOR DEATHTotal:2