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National Insurance Company Li mited Regd. Office: 3 Middleton Street, Kolk ata – 700 001 CLAIM FORM FOR OVERSEAS MEDICLAIM POLICY (To be submitted to below mentioned address for lodging claim) CORIS INTERNATIONAL 8 RUE AUBER, 75009, PARIS, FRANCE Name of Person Claiming : Mr. / Mrs. Home Address in India : Occupation: Day : __________ Time : ____________ Tel No. : _________________ DETAILS OF POLICY C.O. CODE OFFICE CODE PLAN CATEGORY SERIAL NO Date – Policy Issued: Date – Trip Commenced : No. of Days : Scheduled Date of Return: Geographical Limits Worldwide Excl. Worldwide Incl. USA / CANADA USA / CANADA NAME AND AGE OF EACH PERSON INCLUDED IN THE CLAIM Date of Birth Mr. / Mrs. / Miss. Initials Surname ____ / ____ / DD MM YY POLICY SECTION RELATING TO CLAIM (Tick Boxes) Medical Expenses Personal Accident Loss of Checked in Baggage Delay of Checked in Baggage Loss of Passport Personal Liability DATE OF CLAIM OCCURANCE: TRIP DESTINATION: Policy Number PLEASE COMPLETE APPROPRIATE SECTION OF CLAIM FORM AND READ CAREFULLY THE INSTRUCTIONS RELATING TO SUPPORTING DOCUMENTS REQUIRED. WHEN COMPLETED PLEASE SIGN DECLARATION : I Declare that to the best of my knowledge all particulars contained in this form are true. I also authorize Coris to obtain my medical records or information necessary to process the claim. Signed: Date: Place:

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