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Get Igi Insurance Claim Form

OPD CLAIM FORM TO BE FILLED BY EMPLOYEE NAME OF EMPLOYEE DEPARTMENT WITH HIS/ HER IGI HEALTH CARD ID NAME OF PATIENT FOR WHICH CLAIM IS MADE AGE RELATION WITH EMPLOYEE encircle the right choice PERIOD FOR WHICH CLAIM IS MADE MONTH DETAILS OF AMOUNT CLAIMED Self Spouse Daughter Son AMOUNT IN Rs. INVOICE TOTAL AMOUNT CLAIMED CHECKLIST Use separate claim forms if bills are for more than one patients / persons. Please ensure to attach the following documents along with this claim form* Prescription of the doctor if amount claimed is more than Rs. 250/ -. Invoices of the pharmacy /doctor /lab etc* We the undersigned do hereby declare that to the best of our knowledge and belief the foregoing particulars are true and correct. We authorize IGI to obtain information from Doctor/Hospital/Pharmacy/Lab concerning the treatment for which claim is made. INVOICE TOTAL AMOUNT CLAIMED CHECKLIST Use separate claim forms if bills are for more than one patients / persons. Please ensure to attach the following documents along with this claim form* Prescription of the doctor if amount claimed is more than Rs. Please ensure to attach the following documents along with this claim form* Prescription of the doctor if amount claimed is more than Rs. 250/ -. Invoices of the pharmacy /doctor /lab etc* We the undersigned do hereby declare that to the best of our knowledge and belief the foregoing particulars are true and correct. 250/ -. Invoices of the pharmacy /doctor /lab etc* We the undersigned do hereby declare that to the best of our knowledge and belief the foregoing particulars are true and correct. We authorize IGI to obtain information from Doctor/Hospital/Pharmacy/Lab concerning the treatment for which claim is made. INVOICE TOTAL AMOUNT CLAIMED CHECKLIST Use separate claim forms if bills are for more than one patients / persons. Please ensure to attach the following documents along with this claim form* Prescription of the doctor if amount claimed is more than Rs. 250/ -. Invoices of the pharmacy /doctor /lab etc* We the undersigned do hereby declare that to the best of our knowledge and belief the foregoing particulars are true and correct. Please ensure to attach the following documents along with this claim form* Prescription of the doctor if amount claimed is more than Rs. 250/ -. Invoices of the pharmacy /doctor /lab etc* We the undersigned do hereby declare that to the best of our knowledge and belief the foregoing particulars are true and correct. We authorize IGI to obtain information from Doctor/Hospital/Pharmacy/Lab concerning the treatment for which claim is made..

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