ALL FIELDS IN THIS FORM ARE MANDATORY (Data will be kept confidential)

Claim Number (If Available): 13-FGH-22-3-267765-01

POLICY / INSURED DETAILS

Policy No : FGH-13-21-7002271-02-000 Health Card No. of Patient: FGH1391176C-02

Policy Start Date : 01/01/2022 Policy End Date: 31/12/2022 Date of Joining the Policy: 01/01/2022
Corporate Name : Apple India Private Limited (Only for Group Policies) Employee ID: 623986

PERSONAL DETAILS OF EMPLOYEE/PROPOSER

1 Name of the Employee / Individual: Srinivasa Raghavan N

2 E-Mail address of the Employee/Individual: [email protected]
3 Mobile Number : 9629762475
4 Permanent Account Number (PAN): Aadhar Card No :

1 Name of the Patient: S Shrinidhi

2 Relationship with the Employee / Propose : self spouse ⦿ child parent others
3 Date of birth of claiment: 08/04/2019 Age: 2 Years Gender: Male ⦿ Female others
4 Residential Address: wing 10 303, Ahad euphoria, Kodathi, Bangalore

Claiment/Patient Details

Total claimed Amount : 800.00

Claimed Amount in Words: Rupees Eight Hundred Only

1. Diagnosis:Allergy Enclosure Check List :

2. Admission Date: 02/07/2022 Discharge Date: 02/07/2022 1.Original discharge summary containing all relevant details.
3.Name of Treating Doctor:_____________________________________
Ganesh 2. All original bills and their pre-numbered receipts duly signed with a revenue stamp.
4. Mobile No. of Treating
3. Copies of all reports & prescriptions.
Doctor:_________________________________
NA

5. Name of family physician: ____________________________________

NA 4.First prescription / consultation letter from your Doctor.
6. Mobile no. of family physician:
5. Copy of proposer/employee photo ID proof & address proof.
_________________________________
7. Details of other existing Health Policies :_________________________
NA
6. NEFT Form with photocopy of cancelled cheque with printed name of proposer /
employee.
__________________________________________________________
8. Ongoing Medication
:________________________________________
NA
CONSENT REQUIREMENT FOR ACCESS TO TREATMENT PAPERS / INDOOR CASE SHEETS / MEDICAL RECORDS / INVESTIGATOR VISIT

I hereby authorize Future Generali India Insurance or any agency / individual authorized by them to obtain copies or review in person all my medical records including
but not limited to admission notes, treatment sheets, indoor case papers, investigation reports, prescriptions and all other documents present in the hospital case file.
Details related to my past hospitalisations in your hospital can also be provided / shown to Future Generali or its authorized representatives. I agree that all information
provided above by me in the claim documents is true and that if I have provided any false or untrue information, my right to claim the reimbursement of expenses shall be
absolutely forfeited.

Name of Patient / Relative :_______________________________________________

Father
Relationship with Patient:_________________________________________________Signature Srinivas

of Patient / Relative:_____________________________________________

Date: DD_/_MM_/_YYYY 26/12/2022

Future Generali India Insurance Company Limited Registered office address : Indiabulls Finance Centre, Tower 3, 6th Floor, Senapati Bapat Marg, Elphinstone (W),
Mumbai - 400 013 Corporate Identity No (CIN): U66030MH2006PLC165287 Telephone No 022 4097 6666 and Fax No 22 4097 6900 Email:
[email protected] website address www.futuregenerali.in DIP001 – Claim Form

Please attach this form in Original to the hospital bill and other claim documents. Separate claim form required for each claim. PLEASE ENCLOSE A PHOTOCOPY
OF THE FUTURE GENERALI HEALTH ID CARD.

Name as per Bank Account Apple India Private Limited

Bank Name HSBC BANK
Branch Name & Address Chennai Main Branch
Branch MICR Code
Branch IFSC Code for NEFT H S B C 0 6 0 0 0 0 2
( Please attach a photocopy of a cheque or a blank cheque of your bank duly cancelled for ensuring accuracy of the bank name, branch name, account number &
name of account holder printed)
Account Type Saving ✓ Current Cash / Credit
Account No. (as appearing in Cheque Book) 0 4 1 3 3 5 4 9 8 0 0 6
Bank Authorization &
Stamp
HR Authorization & Stamp
(Mandatory for Retail
(Mandatory for Group Policies
Policies
in case cheque or passbook
in case cheque or
copy not available)
passbook
copy not available)

AUTHORIZATION FOR TRANSFER OF CLAIM AMOUNT BY NATIONAL ELECTRONIC FUND TRANSFER

I hereby declare that the particulars given above are correct

NA and complete and request you to remit any amount due to me, if any to the aforesaid bank account. I
herewith further declare that if any transaction is delayed or not effected at all or is wrongly credited to any other account for reasons of incomplete or incorrect
information as provided above, I shall not hold Future Generali India Insurance Company Ltd (“Company“) or any of its directors, employees or agents responsible for
the same. I also declare that the remittance of any dues to the aforesaid bank account shall be considered as full and valid discharge of its obligations by the company. I
also undertake to advise any change in the particulars of my bank account to facilitate updation of records for the purpose of credit of any amount due, through NEFT.
Name of Employee / Proposer: Signature of Employee / Proposer:
Policy No. Claimant Name: Date:

FEEDBACK AND SUGGESTIONS

We thank you for choosing Future Generali as your Insurance provider. We always strive to ensure that our service levels exceed our customer’s expectations.In the
spirit of this endeavor, we will greatly appreciate your valuable inputs and feedback. Kindly provide your feedback on your experience with Future Generali and any
suggestions for improving our services. We value your time and promise to evaluate your suggestions for improvement of our service.