H E A LT H C H E C K U P R E I M B U R S E M E N T F O R M

SECTION A - DETAILS OF POLICY HOLDER

Policy Holder’s Name Policy No.
SECTION B - DETAILS OF INSURED PERSON
Insured Person’s Name (For whom claim is being made)
Relationship of Insured Person with Policy Holder (Self/Spouse/Child/Father/Mother)
Address

Gender : Male  / Female  Telephone No. Mobile No (Mandatory)

E-mail ID, if any
SECTION - C DETAILS OF BILLS ENCLOSED
Sr No. Bill No Date Issued By Towards (Health check up) Amount (Rs)
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
SECTION - D DETAILS OF POLICY HOLDER’S BANK ACCOUNT
(Please note - Reimbursement for health check up benefit would be made by NEFT only. It is mandatory to furnish below mentioned details)
PAN Canara Bank Account Number (13 digit)
Canara Bank Branch
IFSC Code MICR No *please attach a cancelled cheque pertaining to the same

Note: It is agreed that the Policyholder will intimate in writing to Apollo Munich Health Insurance Co. Ltd. about any change in bank account details.
SECTION E - DECLARATION BY THE POLICY HOLDER
I hereby declare that the information furnished in this reimbursement form is true & correct to the best of my knowledge and belief. If I have made any false or
untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall
be forfeited. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim, if any.

Date : D D M M Y Y Place : Signature of Policyholder :

Please follow the below mentioned simple steps to reimburse expenses:

Step 1: Submit bills/receipt in original (mandatory) along with copy of health check-up report (optional) and duly filled and signed reimbursement form at any of
our Apollo Munich Branch office or courier to

Claims Department, - For Canara Bank Health check-up reimbursement

Apollo Munich Health Insurance Co. Ltd Apollo Munich Health Insurance Co. Ltd.
Ground floor, Srinilaya - Cyber Spazio, iLABS Centre, 2nd & 3rd Floor,
Suite # 101,102,109 & 110, Ground Floor, OR Plot No 404 - 405,
Road No. 2, Banjara Hills, Udyog Vihar, Phase – III,
Hyderabad-500 034 Gurgaon-122016, Haryana

Step 2: In case of any deficiency in the documents/information submitted by you, we will send a deficiency letter within 7 days of receipting such documents.
Step 3: On receipt of the complete set of documents, we will process the admissible amount within 15 days via NEFT

Please Note
· This benefit is available on renewal of your policy
· The health check-up invoice submitted for reimbursement must be of a date which is on or after the commencement of renewed policy period.

Email: servicecanara@apollomunichinsurance.com | www.apollomunichinsurance.com

Apollo Munich Health Insurance Co. Ltd. • Central Processing Center, 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon-122016, Haryana • Corp. Off. 1st Floor,
SCF-19, Sector-14, Gurgaon-122001, Haryana • Reg. Off. Apollo Hospitals Complex, Jubilee Hills, Hyderabad-500033,Telengana • Canara Bank is an IRDA licensed corporate agent (CA license No.
983218) of Apollo Munich Health Insurance Company Limited (“AMHI”). This Insurance policy is underwritten by AMHI. Participation by Canara Bank customers shall purely be on voluntary basis.
For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale. • IRDA Registration Number - 131 • Corporate Identity Number: U66030AP2006PLC051760