FORM-1

NATIONAL INSURANCE COMPANY LIMITED

DOMICILIARY CLAIM FORM FOR (OUT PATIENT TREATMENTS)
Medical Benefit Sce!e f"# Office$E!%l"&ee' D"!icilia#& etc( T#eat!ent clai! f"#!
Office )'e*
P"lic& N"+
OFFICE USE* L"t n"+
Clai! N"+
NAME OF EMPLOYEE*
C"!%an&* TATA PRO,ECTS LTD
M#$ M'+ RA,-IRAN+B
E!%l"&ee N"+ *
TPL ./01
LOCATION*
(P#e'ent %lace "f P"'tin1)
MAN2AON( RAI2AD
NAME OF T3E PATIENT RAS3MI RE23UNAT3
Relati"n'i% 4it E!%l"&ee 5IFE
NAME OF ILLNESS $ TREATMENT
TA-EN FOR*
PRE2NENCY
Plea'e Menti"n Illne'' detail'
C"n')ltant' Fee' R'+ 677
C"'t "f Medicine' B")1t f#"! Ce!i't$
D"ct"# a' %e# %#e'c#i%ti"n
R'+ 1066
N"+ "f Bill'8888 attaced 10 bills total
Bill' and In9e'ti1ati"n Re%"#t' attaced R'+ 1.:7
Dental T#eat!ent' (Bill' and
P#e'c#i%ti"n t" ;e attaced)
R'+NA
TOTAL CLAIM AMT+ R'+ ::<6
In #e'%ect "f te e=%en'e' inc)##ed( encl"'ed te f"ll"4in1 d"c)!ent'*
1 P#e'c#i%ti"n "f te D"ct"#
0+ C"n')ltati"n Fee' Recei%t
:+ Dia1n"'tic $ Pat"l"1ical Te't Re%"#t' > Recei%t'
?+ Ce!i't Bill' in "#i1inal ')%%"#ted ;&
D"ct"#@' %#e'c#i%ti"n
N"te* 5it")t te a;"9e encl"')#e' n" clai! 4ill ;e ente#tained "#
'ettled( and te 'a!e 4ill ;e #et)#ned t" te indi9id)al+
I e#e;& 4a##ant tat te t#)t "f te f"#e1"in1 %a#tic)la#' in e9e#& #e'%ect and I a1#ee tat
if I a9e !ade "# 'all !aAe an& fal'e "# )nt#)e 'tate!ent( ')%%#e''i"n "# c"nceal!ent !&
#i1t "f #ei!;)#'e!ent 'all ;e a;'"l)tel& f"#feited and I 'all #ende# !&'elf lia;le t"
di'ci%lina#& acti"n )nde# te 2ene#al In')#ance (C"nd)ct( Di'ci%line and A%%eal) R)le'(
1</.
Date*
Si1nat)#e "f E!%l"&ee