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Get United India Claim for Health Insurance Policies - Part A

S Form is not to be taken as an admission of liability (To be filled in block letters) DETAILS OF PRIMARY INSURED a) Policy No. b) SI. No./Certificate No. c) Company/TPA ID No. d) Name e) Address City State Pin Code Ph. No. Email ID DETAILS OF INSURANCE HISTORY a) Currently covered by any other Mediclaim/Health Insurance Yes No b) If yes, Company Name Policy No. Sum Insured (`) c) Date of commencement of first Insurance without break (Copies of Policies to be attached) ___ / ___ / .

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