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CLAIM FORM SAFEWAY MEDICLAIM SERVICE PVT. LTD. 6/2 First Floor Industrial Area Kirti Nagar New Delhi-15 Tel 011-41425671/2511464823 25114822 Fax 011-41425672/912266466797 Email-support safewaymediclaim.com Name of the Insurance Company Policy No. Safeway Id. Card no. Nature of illness Name of the Claimant Address Contact No E-mail Name of the patient Relation with Claimant Age Sex M / F Date of injury sustained or Disease first detected DD/MM/YYYY Hospital Name and address Regd. No* No* of Beds Name and Address of attending Doctor Regd. No* Admitted on Date Time Discharged on Date Time IPD No* / File No* Room No Type of Room Total Amount Claimed Rs. Whether Cashless Facility / claim availed earlier if yes please provide details Previous coverage details if any I HAVE NO OBJECTION IN SAFEWAY MEDICLAIM SERVICES PVT LTD. OBTAINING DETAILS OF MY TREATMENT / COLLECTING DOCUMENTS AND / OR VERIFYING HOSPITAL RECORDS* THIS MAY BE TREATED AS MY CONSENT FOR 1VERIFICATION OF HOSPITAL RECORDS CONCERNING MY ADMISSION 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 SUPPRESS OR CONCEAL ANY MATERIAL FACT THEN MY RIGHT TO CLAIM REIMBURSEMENT OF THE SAID EXPENSES WOULD STAND FORFEITED. I FURTHER DECLARE THAT IN RESPECT OF THE ABOVE TREATMENT NO BENEFITS ARE ADMISSIBLE UNDER ANY OTHER MEDICAL SCHEME OR INSURANCE* Signature Insured / Claimant In support of the above claim Please enclose the following documents in original - Copy of ID Card. Completely filled and signed claim form* Original detailed Discharge Summary Final bill of the hospital and the payment receipts in original* Package Break-up details if applicable All the investigation reports in original* All the medicine purchase vouchers with supporting prescriptions in original* Record of treatment taken in Pre post hospitalization periods if any. Card no. Nature of illness Name of the Claimant Address Contact No E-mail Name of the patient Relation with Claimant Age Sex M / F Date of injury sustained or Disease first detected DD/MM/YYYY Hospital Name and address Regd. No* No* of Beds Name and Address of attending Doctor Regd. No* Admitted on Date Time Discharged on Date Time IPD No* / File No* Room No Type of Room Total Amount Claimed Rs. No* No* of Beds Name and Address of attending Doctor Regd. No* Admitted on Date Time Discharged on Date Time IPD No* / File No* Room No Type of Room Total Amount Claimed Rs. Whether Cashless Facility / claim availed earlier if yes please provide details Previous coverage details if any I HAVE NO OBJECTION IN SAFEWAY MEDICLAIM SERVICES PVT LTD. Whether Cashless Facility / claim availed earlier if yes please provide details Previous coverage details if any I HAVE NO OBJECTION IN SAFEWAY MEDICLAIM SERVICES PVT LTD. OBTAINING DETAILS OF MY TREATMENT / COLLECTING DOCUMENTS AND / OR VERIFYING HOSPITAL RECORDS* THIS MAY BE TREATED AS MY CONSENT FOR 1VERIFICATION OF HOSPITAL RECORDS CONCERNING MY ADMISSION 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 SUPPRESS OR CONCEAL ANY MATERIAL FACT THEN MY RIGHT TO CLAIM REIMBURSEMENT OF THE SAID EXPENSES WOULD STAND FORFEITED.

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