Bajaj Allianz General Insurance Company Ltd
OPD Claim Form
I. POLICY DETAILS
Proposer Name: _______________________________________________________________________
OPD_Policy Number: ________________________________________________________________________
Address: _____________________________________________________________________________
Mobile Number: _______________________________Email ID:-________________________________
II. OUTPATIENT CONSULTATION DETAILS:
Name of the Member in respect of whom claim is made: ______________________________________
Date of Consultation: __________________________________________________________________
Diagnosis: ___________________________________________________________________________
Total Claim Amount: ____________________________________________________________________
III.POLICY HOLDER BANK ACCOUNT DETAILS (FOR ECS TRANSFER OF CLAIM SETTLEMENT):
Please furnish the details below along with copy of cancelled cheque
Name of the Account Holder ( As per Bank Account):______________________________________
Bank Account No: _____________________________________________________________________
Bank Name: __________________________Bank Branch: _____________________________________
IFSC Code: ___________________________________MICR Code: _______________________________
Account Type: Saving Current Cash Credit
PAN: _______________________
IV. Details of Bills Enclosed
Sr. No. Bill No. Bill Date Issued By Amount
Regd & Head office: Bajaj Allianz House, Airport Road, Yerwada Pune 411006. Tele (+91 20)
66026666 Fax (+9120) 66026667, Email: [email protected]
Website: https://www.bajajallianz.com/general-insurance.html
Bajaj Allianz General Insurance Company Ltd
V.CHECK LIST OF ENCLOSURES:
Duly filled and signed Claim Form.
Photocopy of ID card / Photocopy of current year policy.
Original Medicine bills, original payment receipt.
Original Investigations bills, original payment receipt with report.
Original Consultation bills, original payment receipt with prescription.
Details of any Outpatient Procedures, If any
Dental X-ray film
IV.DECLARATION BY THE INSURED:
I hereby declare that the information furnished in this claim form is true & correct to the best of my
knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any
material fact with respect to questions asked in relation to this claim, my right to claim reimbursement
shall be forfeited. I also consent & authorize Bajaj Allianz General Insurance Company Limited, to seek
necessary medical information / documents from any hospital / Medical Practitioner who has attended
on the person against whom this claim is made.
Date: _________
Place: ___________ Signature of Insured ___________________
I/We authorize Insurance Company/TPA to contact me/us through SMS/Email/WhatsApp for any update on this claim.
Regd & Head office: Bajaj Allianz House, Airport Road, Yerwada Pune 411006. Tele (+91 20)
66026666 Fax (+9120) 66026667, Email: [email protected]
Website: https://www.bajajallianz.com/general-insurance.html
