ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LIMITED

46, Whites Road, Chennai – 600 014.

Phone: 044 – 851 7387-90 Fax: 044 - 851 7384

For Office Use only

CLAIM NO: Issuing Office __________
Date of issue __________

HEALTH PREMIUM PLATINUM – CLAIM FORM

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

Please ensure that all questions are answered in capital letters using an ink pen

1. Policy No. 2. Membership No.

2. Name of the employee

3. Employee No.

4. Address with Pincode

E-Mail ID

5. Telephone Number Off: Res:

6. Details of the Insured Person (in respect of whom the claim is made)

Name

Date of Birth DD/MM/YY

7. Details of illness
Date on which detected DD/MM/YY

Nature of Illness/Disease

8. Details of the Hospital/Nursing Home

Name of the Hospital/

Nursing Home
 Address & Telephone No.

Date of Admission DD/MM/YY Time

Date of Discharge DD/MM/YY Time

9. Amount Claimed

Hospitalisation expenses Rs.

Pre Hospitalisation expenses Rs

Post Hospitalisation expenses Rs

Total Rs.

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made any false statement,
suppression or concealment, my right to claim under the policy shall be forfeited. I further declare that, in respect of the
above treatment, no benefits are admissible under any other Medical scheme or Insurance.

I also consent and authorise the insurers to seek medical information from any Hospital/Medical practitioner who has
any time attended on the insured person.

Date :
Signature or thumb
impression of the
Place : Insured.
__________________________________________________________________________________________________________

Before sending the claim form ensure that you submit

 Original Bills, Receipt and Discharge certificate / card from the Hospital.
 Original Cash Memos from hospital(s)/Chemist(s), supported by the proper prescriptions.
 Copies of charge slips if payment is made by credit card
 Original Receipt and Pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner /
Surgeon demanding such Pathological tests
 Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s original bill and receipt, and certificate regarding diagnosis.
 Medical History Summary.
 FIR incase of accidental injury.
 MEDICAL CERTIFICATE TO BE FILLED IN BY THE ATTENDING PHYSICIAN

Name and address of the patient

1. Age of the patient

2. Name and address of the Surgeon(s)/Physician

3. Date and time of admission Date Time

4. Date and time of discharge

Date Time

5. Diagnosis

6. Date of first consultation

(prior to hospitalisation)

7. a.With what complaints was the patient admitted for?

b. Since when was the patient suffering from the

said complaints?

8. Please give previous medical history of the patient

9. Is the ailment/injury a complication of a pre-existing disease

or a condition? If yes, please give details

10. Is the present ailment/injury attributable to the influence of alcohol

or intoxicating drugs?

11. Is the present ailment/injury congenital in nature?

If yes, please give details.

13. If hospitalisation is for maternity, please give

LMP, EDD & Gravida

14. a. Is the Hospital/Nursing Home registered?

If yes, please give registration number.

b. How many in-patient beds does the Hospital have (including ICU)?

c. Does the hospital have a fully equipped operation theatre,

qualified nurses and doctors round the clock?

14. Any other remarks you wish to make

Doctor’s name Signature of the doctor

Address and seal

with
Registration Number Date