MEDICLAIM INSURANCE - CLAIM FORM (To be submitted to M/sGHPL)

POLICY NO: CLAIM NO: DATE:

01. Name of the Corporate Texas Instruments (India)

02. Name of the Insured person (Employee) Akhilesh Malladi
03. Employee No. A0132118
04. Contact No. & E-mail ID (if any) 9945673372 akhilcoolb4u@gmail.com
05. Name of the patient Akhilesh Malladi
06. ID Card No. of the patient GHNI0100024311
07. Relationship with employee, Age & Sex Self, 26, Male
08. Sum Insured of the patient under the policy
09. Nature of illness Typhoid fever
10. Name of the Hospital where treated and Chinmaya Mission Hospital, Indiranagar, Bangalore
Address of the Hospital VIMS Hospital, Marathahalli, Bangalore
11. Date of Admission 31/05/2015
12. Date of Discharge 02/06/2015
13. Cashless / Reimbursement (Specify) Reimbursement
14. Amount Claimed in Rupees 25488.72
(As per the details below)

Sl. Bill No. Date Amount Sl. Bill No. Date Amount
No. No.
1 RCA2445064 28/05/ 2015 200 6 RCA2448004 30/05/ 2015 200

2 10320 28/05/ 2015 214.72 7 PQA0952333 30/05/ 2015 307

3 PQA0951327 28/05/ 2015 429 8 VIMS/ 2015- 02/06/ 2015 21260

2016/ 26995
4 RCA2445187 28/05/ 2015 1260

5 PQA0951682 28/05/ 2015 20 9 164 01/06/ 2015 828

10 10404 06/06/ 2015 770

(Please attach a separate sheet for more number of bills and receipts) TOTAL 25488.72

I/We hereby declare that the above details are true to the best of my/our knowledge and belief that I/We not suppressed any information

In support of the claim, I enclose the following documents (Please indicate by ) :-

Claim form duly filled and signed Pre Hospitalization Bills & No(s)of Bills.
GHPL Pre-authorisation form Post Hospitalization Bills & No(s)of Bills.
Claim Notification Hospital Payment Receipt
Discharge Summary Investigation Report with Dr's request
Hospitalization Bills 1. MRI Yes/No 2. CT Scan Yes/No
Doctors Surgery Certificate if any 3. ECG Yes/No 4.X-ray Yes/No 5. US Scan Yes/No
Surgery / Consultation Bills if any Lab Reports with Dr's request No(s).of Rep
Medicines Bills with Dr's prescription Others if any

Signature of the Employee