The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001

CLAIM FORM FOR RASTA APATTI KAVACH

(JANATA PERSONAL ACCIDENT INSURANCE WITH MEDICAL EXPENSES ARISING OUT OF ROAD ACCIDENT)
Policy No. ...........................				Claim No............................

1.	Name of insured Person: ____________________________________________  
          
     2. Name of the Injured / Deceased Person: __________________
i)	Whether occupant:  Y/N
ii)	Whether Third Party:  Y / N If yes, pedestrian / cyclist/ ___________
iii)	Whether Driver: Y/ N If yes, license No. __________RTO___________

     3. a) Date & time of Accident:  Date :_________________Time:_______ a.m./p.m
        b) Place of Accident: _____________________________
        c) Details of Accident: ____________________________
        d) Whether intimated to Police: Y / N, Police Station ________________________
        e) FIR/SDE No.:              No. ________________Date______________________

    4. If Injury i) Nature of Injury: _____________________________
                    ii) Extent of Injury: ______________________________
                    iii) Medical Practitioner (Who has attended the patient): ________________
    		               a) Name: _________________________
			     b) Address: ____________________________________
					______________________________________
                     iv) Hospital/ Nursing Home (Where treatment is taken):____________
a)	Name
b)	Address/Phone Numbers

V) Treatment Details
                                   a) Period of Treatment:
                                   b) Date of Admission: 
                                   c) Date of Discharge:

vi) SCHEDULE OF EXPENSES INCURRED BYTHE CLAIMANT
Details of Expenses claimed under Hospitalisation/Domiciliary Hospitalisation.
(to be supported by Bills/Receipts , Cash Memos etc.)	Amount Claimed 
Rs. (1)	Amount not payable 
Rs. (2)	Net Payable	
A)	HOSPITALISATION BENEFITS:
a) Room Board, Nursing Expenses
    For ............ days............
b) IC Unit for ........days ....... Rs..............per day.
B)	SURGICAL & NON-SURGICAL       DISEASE:
a) Surge on & Anaesthetist fees.......
b) Anaesthesia, Blood, Oxygen, Operation Theatre, Surgical Appliances .....................
c) Diagnostic Materials & X-Ray
d) Medical Practitioner
    Consultant and Specialist fees for
    Consultations / visits..........
e) Medicines & Drugs:
a)	Supplied by Hospital .......
b)	Purchased from Chemists....... 				

	       vii. In case of Disablement:
a)	Disability Factor: Enclose Disability Certificate in Original _________
b)	Certified by: ____________________________________
c)	Claimed: _______________________________________

     5. In case of Deatth
i)	Post Mortem Report Date: ______________________
ii)	Death Certificate Date: __________________________                                                                                         
iii)	Legal heir Certificate / Date: ______________________
iv)	Nominee's Name: _______________________________ Age: ___________                                                                                   Relation with deceased:
                  Address:                                                                                                        
         v)      Claimed Amount:__________________________
     6. Whether any other JPA Insurance Policy is there? Yes/No If yes Sum Insured ______
         Insurance Company:                                                                                               
         In support of the above claim, I enclose the following documents                                            
        (Please tick the documents enclosed).                                                                                1. Bill Receipt and Discharge Certificate/card from the Hospital
      2. Cash Memos from the Hospital-/ Chemist (s), supported by the proper prescription.                               
           3. Receipt and Pathological test reports from a Pathologist supported by the note from     the Hospital/Medical Practitioner / Surgeon demanding such Pathological tests.          
           4.  Surgeon's certificate stating nature of operation performed and Surgeon's Bill &  receipt. 
           5.  Attending Doctor/ Consultant/ Specialist/ Anaesthetist’s bill and receipt and  certificate  regarding diagnosis:-      
6. Certificate from the attending Medical Practitioner/ Surgeon that the Patient is fully cured. 
7. Postmortem Certificate
          8. Death Certificate         
	9. Legal heir Certificate 
	10. Copies of other JPA insurance policies existing at the time of accident

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall made or shall make any false or untrue statement, suppression or concealment, 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 admissible under any other Medical Scheme or Insurance.

	Dated at .............................. this  ............... day of .......................20......

				
									SIGNATURE OF CLAIMANT

FOR OFFICE USE:

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