The New India Assurance Company Limited 87, M. G. Road, Fort, Mumbai, India – 400 001

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                                                                                    MEDICAL AND EMERGENCY EXPENSES

I ) DOCUMENTS REQUIRED :

The following documents must be enclosed with your completed claim form :

• ORIGINAL CERTIFICATE OF INSURANCE TOGETHER WITH ANY COPIES OF AIRLINE TICKET
• ORIGINAL BILLS OR RECEIPTS FOR FULL AMOUNT OF CLAIM ( PHOTOCOPIES NOT ACCEPTABLE )
• CONFIRMATION BY HOSPITAL OF DATES OF HOSPITALISATION ( FOR CLAIMS FOR HOSPITAL BENEFITS )
• THE MEDICAL CERTIFICATE DOES NOT NEED TO BE COMPLETED FOR MINOR ACCIDENTS OR ILLNESS
• PHYSICIAN’S REPORT ( ORIGINAL ATTACHED TO THE POLICY IF APPILCABLE )

These documents must be supplied with the completed claim form at the Claimant’s expense. Failure to do so will delay the processing of your claim and could result in it being declined.

II ) TO BE COMPLETED BY THE CLAIMANT OR THE CLAIMANT’S LEGAL REPRESENTATIVE :

1. Name of Sick or Injured Person :
    
2. Nature of Injury / Illness :
    
3. Date of Injury / Illness :
    
4. Place of Injury / Illness :
    
5. Circumstances of Injury :
    
6. If claim was due to hospitalization or confinement, was the Emergency Assistance Department contacted YES / NO. If no, please advise why, on an additional information sheet.
    
7. Dates of Hospitalization :                                               From -                                                 To –
    
8. Details of Claim :
    
9. Details of any third parties involved in accidental injury or death of insured person.
    
10. Details of Private Health Insurance