UNITED INDIA INSURANCE COMPANY LIMITED

TPA-Medi Assist India Pvt Ltd

B-20, Sector 2, Noida-201301

Domiciliary Claim Form

1. Claim Number (for Medi Assist Use) 2. Policy Number 3. Employee ID Number 4. Employee Name 5. MAID No. 6. (a) Name Of Claimant ( in respect of whom the claim is made) (b) Relationship to the Employee (c) Present completed age (d) Occupation (e) Residential Address (f) E-mail ID (g) Contact No- (landline / Mob) 7. Nature of disease/illness contracted or injury suffered or complete diagnosis 8. Details of Domiciliary Hospitalisation (a) Date of Commencement of treatment (b) Date of Completion of Treatment (c ) Name and Address of Attending Medical Practitioner (d) Telephone No. (e) Registration No. 9. Schedule of Expenses incurred by the claimant under domiciliary claims (to be supported by Original Bills/cash receipts, Cash memos, etc.) Pharmacy/ Medicine Expenses Domiciliary Hospitalisation Benefit I hereby declare that the foregoing statements are true in every respect and are made without any reservation. I also declare that I do not get nor I am likely to get any medical benefits for the above illness from any other source. I consent and authorized the insurers / TPA to seek medical information from any hospital/medical practitioner who has at any time attended concerning the claim. Consultation Expenses Investigations Expenses Total Expenses

Date:

Signature of Claimant