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Claim intimation form seek information from the insured individual about self, illness he/ she is suffering from and kind of treatment against which the claim is filed. Apollo Munich explains the procedure to be followed while filing the claim. The form is to be filled to intimate the insurer about the treatment to be availed and the related expenditure. It includes information about the policyholder, the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company work over it. Complete submission of the required documents is extremely important. It will affect the kind of coverage offered by the insurer.
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Apollo Munich Health Insurance Co. Ltd. 10th Floor, Tower-B, Building No. 10,
DLF Cyber City, DLF City Phase -II, Gurgaon, Haryana-122002ToLL Free 1800-102-0333 • www.apollomunichinsurance.com • e-mail : [email protected]
e-mail : [email protected] ToLL Free 1800-102-0333 www.apollomunichinsurance.com
CLAIM INTIMATION FORM
1. Apollo Munich Health Member ID Number:
2. Policy Number :
3. Name of proposer :(in whose name policy is issued)
First Name :
Last Name :
4. Name of person admitted: First Name :
Last Name :
5. Date of Birth / Age: (DD__ __ /MM __ __/YYYY __ __ __ __ ) __________________Years
6. Address :
City: State: Pin:
7. Date of loss/Treatment/Event :
8. Unique ID of Provider, If any :
9. Provider Name :
10. Provider address in case of non-network:
11. Provisional Diagnosis :
12. Treatment Planned :
13. Estimated Expenses : Rs.
14. Estimated length of stay (for inpatient treatment)
_ __ __ Days
15. Contact details, if changed :
16. Intimating Persons :
17. Admitting Doctor details :
Date:
Place: Signature of person suffering injury or legally authorized representative
AMH
I/PR
/H/0
021/
0006
/102
010/
P
