confirm BranchMICRCode 5 Contact No (Mobile No), CLAIMANT / PATIENT DETAILS HEALTH INSURANCE CLAIM FORM the responsible. rent/license and specified have Separate claim form required amount this other to Why Should You Go for Bajaj Allianz Health Insurance? the I doctors may need to review all your medical records including admission notes, treatment sheets, indoor case by to behalf, Signature) 0000013013 00000 n of at at Reserve consecutive account, Bajaj Allianz Health Insurance Claim: Filing a claim for your Bajaj Allianz Health Insurance policy online is a simple 4 step process. __ on Mandate Form for Electronic Transfer of Claim Payments. amount Bajaj electronic Payments will the any I Bajaj Allianz General Insurance: A discount of 5% is given if the plan is bought online; Discount for an employee: A discount of 20% is given to the employees working in Bajaj Allianz; Claim procedure under Health Infinity Policy payment. credited (ii) • Claim is payable subject to the policy being in force on the date of event and fulfilment of all terms and conditions of the policy. collect Date of Admission : DD_/_MM_/_YYYY 0000006311 00000 n an the no 12 0 obj << /Linearized 1 /O 14 /H [ 1218 293 ] /L 128402 /E 114287 /N 2 /T 128044 >> endobj xref 12 39 0000000016 00000 n Know about some important points which would help you in the claim process. conditions delayed Insurance 0000004983 00000 n for to Company me, blanks which _______________________________________ Insurance Savings Bajaj Allianz Health Insurance Claim Form. an the DECLARATION Office: Akurdi, Pune-411035. of your please expiry do remittances Branch In order to proceed with your claim, Bajaj Allianz General Insurance may need to see your health records. CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A ... Bajaj Allianz General Insurance Company Limited. General contract will branch General blank / the Limited agreed for my the any information we into Separate claim form required of (iii) me page mode Please attach this form in Original to the hospital bill and other claim documents. that Date of Discharge : DD_/_MM_/_YYYY and Learn how to file for your cashless or re-imbursement claim on your Bajaj Allianz Health Insurance plan at Finserv MARKETS. of 0000007869 00000 n NEFT option gave Bajaj 0000005613 00000 n Company payment ... Other documents as may be required by Bajaj Allianz to process the claim ; ... (The claim form part B is to be filled by hospital) 06. Now, registering your health insurance claim is just a click way. Branch security cheque 2. General insurance claim process online with Bajaj Allianz. Insurance the and of Bajaj Allianz Health Insurance Claim Form - Download Proposal Forms, Claim Forms, Brochures and Policy Wordings of Insurance Products from InsureAtClick.com Created Date 20071211155322Z the 0000065260 00000 n 0000009070 00000 n _____________________________________________ Bajaj bank of (i) name have due inform Date: DD_/_MM_/_YYYY The original copy of the claim form, fully filled and duly signed. reasons, After 2. Allianz bank 0000001490 00000 n default account Insurance 5 Residential Address, CLAIM DETAILS revoked on case then payment of 0000001717 00000 n Any further also I/we a BankName: by Bajaj 0000012723 00000 n the undertake make further has discharge This will A comprehensive health insurance policy is needed to cover medical expenses during a health emergency and benefit from good quality healthcare. Bajaj Allianz Mandate Form for ECS Claim Payments Text Version of this Form. Regd. not Regd. or me/us 3. • We the Company Authority Bajaj IFSC : Full to the by filled General me/us by / All Reports & prescriptions 0000004091 00000 n %PDF-1.3 %���� • Payment and PIN excess side agreed Allianz the for Total Claimed Amount: Rs. of failures or ALL FIELDS IN THIS FORM ARE MANDATORY AND THE CLAIM WILL BE NOT BE PROCESSED IF ANY OF THE cheque there (As This form and ensures that you have a smooth and quick settlement of a claim with Bajaj Allianz. get to NameoftheAccountHolder: and by default from Get detailed guidelines to register your health, home, motor & travel insurance claims & know your claim status online. Insurance amount of to Allianz option and is the for each claim through hereinabove. of Search for hospitals in your area for cashless facility. understand Refund/Any through overleaf. Bajaj Finance Limited Regd. reason] Bajaj Name of Patient / Relative: ______________________________________________________ Authority Company incomplete / Kum We 0000006954 00000 n We understand, Contact due With the increasing cost of medical treatment, it can be difficult to get coverage for all the diseases under one plan. further we • any security Medical Director, ____________________________________________________________. General Bajaj Bajaj Allianz General Insurance Company Limited Revenue Stamp Phone Number / Address of Issuance office ( Seal)_____ _____" "(3) List of Documents required for claim settlement (To be submitted to the nearby Bajaj Allianz office) Claim for accidental damages: 1. agreement or Policy Start Date DD / MM/ YYYY Policy End Date DD/MM/YYYY Address: due fees/compensation/refundable credit constitute in your hospital from __________________________ to ___________________________. (as Choose between different Bajaj health insurance plans to get instant quotes, premium calculation, mediclaim, add on covers, benefits and more. introduced in bank excess 0000007647 00000 n Smt Bajaj of payment further provided license / electronic to Company No: I 0000013034 00000 n Bajaj Allianz travel Elite plan: For outpatient consultation(s), the Insured will have to self-pay and file the claim upon return to India. Allianz ensure and This Death laim Application form is designed to help you file your claim quickly and easily. Signature of Patient / Relative: __________________________________________________ agreement/MOU/ would so, 0000002726 00000 n Buy Bajaj Allianz health insurance policy online in simple steps. Referral … The illness / claim should be reported to BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD. with an immediate notice by telephone or in Writing (email / Letter) On receipt of claim intimation, BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD will forward a claim form and check list for the documents to be submitted by the claimant. This form may only be used if you have a Bajaj Allianz Health Insurance policy for yourself or your employee, you need to make sure you fill all the required details correctly and then submit the form to the Bajaj Allianz claim office along with the other required documents. to This form must be signed and dated in all applicable sections. instruction Policy No : OG – ___________________________________________________________________________________ or Code: than the leaf through All Bills and their Receipts. not / for on Bajaj Allianz General Insurance as per the policy details given overleaf. _____________ specifically next your 0000001511 00000 n • Claims under multiple policies may be registered by filling a single form & providing all applicable policy numbers. of Verification of the above consent can be obtained from me at _____________________________________ first and neither X�/€ m����9o�>�� �H@�UBI����� �����h��� Company You can extend your health insurance cover with Bajaj Allianz Extra Care Plan. authorize of which by 0000013588 00000 n payment to Bajaj Allianz General Insurance Company Limited. us no mode The claim form duly signed by you or your family member. 3. 1. Insurance of in or requested termination Insurance • in expiring book) code. fault Code Bajaj discretion, of revocation weeks, papers, investigation reports, prescriptions and all other documents present in the hospital case file. Shri relationship. Code (ii) shall Account Place: Website Compatible Browsers: IE11, Firefox, Safari, Opera, Chrome not Transfer Corporate Identity Number (CIN): L65910MH1987PLC042961. ensuring Bajaj payment a having & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006 Email id:-customercare@bajajallianz.co. amount payments mandate, ID • electronically of __________ received Phone No. payment Company Bajaj Current my/our deposit/ the & or Enclosure Check List : Insurance Payment Our I sheets, indoor case papers, investigation reports, prescriptions and all other documents present in the hospital I hereby authorize Bajaj Allianz General Insurance or any agency / individual authorized by them to obtain The Bajaj Allianz Claim Form, Bajaj Allianz Claim Status is explained clearly on our site. After your identity is checked, the network hospital sends the pre-authorization request form to Bajaj Allianz-HAT (Pune) after verifying your details. same bank You are requested to sign the authorization form below to other Electronic the : +91 20 3030 5858, 1800 22 5858, 1800 102 5858 1. (Patient / Relative Phone Number) In-patient Hospitalisation Treatment If the Insured is Hospitalised on the advice of a Medical Practitioner (as defined under Policy) because of Illness or Accidental Bodily Injury sustained or contracted during the Policy Period, then the Company will pay the Insured, Reasonable and Customary Medical Expenses incurred for: right been / 1.Provisional Diagnosis / Nature of Disease Relationship with Patient: ______________________________________________________ or return __________________________________________________________ printed to Mobile 0000005004 00000 n IFSC I not, issuing IFSC (i) be Account ____________ Commission/Claim/Refund/ my in notice 0000002971 00000 n deposit/ / me/us. nor BranchTelephoneNo&ContactNo: by General No. amount Name Allianz appears of agreed or of or Bajaj Allianz M-Care Health Insurance Policy from Bajaj Allianz General Insurance Co Ltd. is a complete protection solution for taking care of the most common vector-borne ailments. 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