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Format No. 10.04.02/F-01/R0 FORM-1-DOMICILIARY CLAIM (OP) Page
No. 01 of 01
FORM-1NATIONAL 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'+
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Format No. 10.04.02/F-01/R0 FORM-1-DOMICILIARY CLAIM (OP) Page
No. 01 of 01
E!%l"&ee N"+ *
LOCATION*
(P#e'ent %lace "f P"'tin)
NAME OF T.E PATIENT
Relati"n'i% /it E!%l"&ee
NAME OF ILLNESS $ TREATMENT
TA0EN FOR*
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Format No. 10.04.02/F-01/R0 FORM-1-DOMICILIARY CLAIM (OP) Page
No. 01 of 01
Plea'e Menti"n Illne'' detail'C"n'ltant' Fee' R'+
C"'t "f Medicine' B"t f#"! Ce!i't$
D"ct"# a' %e# %#e'c#i%ti"n
R'+
N"+ "f Bill' attaced R'
Bill' and In2e'tiati"n Re%"#t' attaced R'+
Dental T#eat!ent' (Bill' and
P#e'c#i%ti"n t" 3e attaced)
R'+
TOTAL CLAIM AMT+ R'+
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8/16/2019 Form 1 Domiciliary Claim Form for Op
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Format No. 10.04.02/F-01/R0 FORM-1-DOMICILIARY CLAIM (OP) Page
No. 01 of 01
In #e'%ect "f te e4%en'e' inc##ed encl"'ed te f"ll"/in
d"c!ent'*
1 P#e'c#i%ti"n "f te D"ct"#
5+ C"n'ltati"n Fee' Recei%t
6+ Dian"'tic $ Pat"l"ical Te't Re%"#t' 7 Recei%t'
8+ Ce!i't Bill' in "#iinal '%%"#ted 3&
D"ct"#9' %#e'c#i%ti"n
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8/16/2019 Form 1 Domiciliary Claim Form for Op
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Format No. 10.04.02/F-01/R0 FORM-1-DOMICILIARY CLAIM (OP) Page
No. 01 of 01
N"te* :it"t te a3"2e encl"'#e' n" clai! /ill 3e ente#tained
"#
'ettled and te 'a!e /ill 3e #et#ned t" te indi2idal+
I e#e3& /a##ant tat te t#t "f te f"#e"in %a#ticla#' in
e2e#& #e'%ect and I a#ee tat
if I a2e !ade "# 'all !a;e an& fal'e "# nt#e 'tate!ent
'%%#e''i"n "# c"nceal!ent !&
#it "f #ei!3#'e!ent 'all 3e a3'"ltel& f"#feited and I 'all
#ende# !&'elf lia3le t"
di'ci%lina#& acti"n nde# te
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8/16/2019 Form 1 Domiciliary Claim Form for Op
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Sinat#e "f E!%l"&ee
