THE NEW INDIA ASURANCE COMPANY LIMITED
Regd. & Head Office : New India Assurance Bldg., 87, M.G. Road, Fort, Mumbai–400 001

Claim form for Pravasi Bhartiya Bima Yojana

Name of Claimant:   Mr. / Mrs._______________________________________________

Home address and
Telephone No. in India        __________________________________________________

				________________________________________________

PERSONAL DETAILS OF INSURED PERSON:

Name Mr. / Mrs.______________________________________________Age__________

Insurance I.D. No.__________________________Valid from __________ to __________

Occupation____________________________Country of Eomployment_______________

POLICY SECTION RELATING TO CLAIM (Tick Boxes)

Section  -  I     (Personal Accident Benefits)					

Section  -  II    (Re-imb. of  Repatriation/Transportation Exp.)		

Section  -  III   (Hospitalization Benefits)					

Section  -  IV   (Re-Imbursement of One Way Air-fare)			

Section  -  V    (Family Floater Hospitalization Cover)

Date of Injury / Illness______________________________________________________

Nature of Injury / Illness____________________________________________________

Place of Injury / Illness______________________________________________________

Details of Expenses Claimed_________________________________________________

________________________________________________________________________
________________________________________________________________________

PLEASE COMPLETE APPROPRIATE SECTION OF CLAIM FORM AND READ CAREFULLY THE INSTRUCTIONS RELATING TO SUPPORTING DOCUMENTS REQUIRED.  WHEN COMPLETED PLEASE SIGN DECLARATION:

I declare that to the best of my knowledge all particulars contained in this form are true.  I also authorize _______________________ Third Party  Administrator to obtain my medical records or information necessary to process the claim.

Date ______________________  Place________________   (Signature) ________________

			

DOCUMENTS REQUIRED:

The following documents must be enclosed with your completed claim form:

1.	Copy of Insurance I.D. Card				) Applicable for all type 
2.	Attested copy of Pass Port (All pages)			) of claims

3.	Death Certificate issued by the Competent Authority	)
4.	Post Mortem Report					)Applicable for Accidental
5.	Certificate/Report of the concerned Indian Embassy 	)Death cases only
Confirming the accidental death				)
6.   Police Report						)

7.   Disability Certificate issued by the Competent Medical  )Applicable for Permanent
Authority alongwith other relevant medical documents  )Total Disability claim

8.   Air-lines tickets alongwith medical advices for the 	)
      accompanying person, if applicable			)
9.	Certificate from the Competent Medical Authorities	)Applicable for claims lodged
Confirming that the insured person contracted the 	)under Sections II & IV only
Major Ailment(s) during the period of employment	)
Contract, if applicable.					)
10.	Documentary proof confirming that service contract	)
Of the insured person is terminated on account of the 	)
Insured perils only						)

11.	Hospital discharge summary alongwith Bill(s)/Cash	)
Memo, Prescription, Investigation Report(s) etc. in 	)Applicable if treatment not 
Original if during the period of work contract,		)taken in the Networking
If applicable.						)Hospital

The required documents must be supplied with the Claim Form duly completed in all respects by the Claimant at his / her expense.  The claimant shall also provide such further documents and information as may be sought by the Company from time to time.  Failure to do so will delay the processing of your claim and could result in it being declined.

 ECS Details of the Insured
 
1	Name of the Insured (as appearing in the Bank Account)		
2	Bank Name  		
3	Branch and address		
4	Bank Account No.		
5	Bank Account Type  		
6	IFSC Code		
7	MICR Code