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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 CONC....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232