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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 claim for coverage under Maxima health plan. 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 to 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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10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002
MaximaClaim Intimation Form (In-Patient)
E-mail : [email protected] ToLL FrEE 1800-102-0333 www.apollomunichinsurance.com
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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 :
7. Date of loss / Treatment / Event :
8. Unique ID of Provider, If any :
9. Provider Name :
10. Provider address with phone number :
11. Provisional Diagnosis :
12. Treatment Planned :
13. Estimated Expenses : rs.
14. Estimated length of stay (for in-patient treatment) _________________ Days
15. Contact details : Mobile No. : Email :
16. Intimating Persons :
17. Admitting Doctor details :
Date :
Place : Signature of Claimant :
City : State : Pin :
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