DOMICILIARY CLAIM FORM The New India Assurance Co Ltd Account: Tata Consultancy Services Limited TATA CONSULTANCY SERVICES LIMITED THE NEW INDIA ASSURANCE COMPANY LIMITED CLAIM NO:100984292 REGD HEAD OFFICE:NEW INDIA ASSURANCE BUILDING 87 MAHATMA GANDHI ROAD, FORT,MUMBAI 400 001 CLAIM DATE:31-03-2012 GROUP HEALTH INSURANCE POLICY NO: 121400/34/11/23/00000140 EMPLOYEE DETAILS Employee Code: 320875 Name: Sanjeev Tayal PATIENT DETAILS Claim Submitted Date: 31-03-2012 Alpha Code: A Patients's Name: Sanjeev Tayal Relationship: Self Ailment Details: Dental Illness Period: From:18-03-2012 To: 31-03-2012 SUMMARY OF EXPENSES Nature of Expenses No of Documents Amount(Rs) Consultation / Prescriptions 2 1200 Diagnostics / Lab tests 1 500 Total: 3 1700 SUPPORTING DOCUMENT -> Original doctors bills & receipts which are numbered & printed -> Original chemists bills & receipts supported with proper prescriptions Please submit the claims documents duly stapled in the following manner to avoid misplacement and enable proper verifications. Order should be . 1.Claim form . 2.Doctor's prescription: This must contain the Nature of ailment, Line of treatment and period of treatment with details of medicines dispensed or prescribed to the Patient. A prescription should not contain payment details) 3.Proper official, numbered doctor's bill from doctor's bill book (should be original). 4.Cash memos for medicines properly arranged if purchased from chemist with prescriptions (should be original). 5.Copies of all LAB and other test reports if applicable and claimed towards same. Also, please note that bills / receipts issued on doctor's letter head will not be acceptable for processing the claim These documents arranged serially as mentioned above while submitting will help in easy and smooth processing of claims. ============================================================== Documents along with dully filled claim form can be dropped in the drop box in your / nearest locations. Or alternately documents can be sent to any of the below (nearest) address. Kolkata Mumbai HIS team (Kolkata) Tata Consultancy Services 1W-16, 1st Floor,Delta Park Eden,Salt Lake Electronics Complex,Kolkata - 700 091,West Bengal,India.:100984292 Corporate HIS Team Tata Consultancy Services Ltd.Wellspring,Desk No.10D-85,Godrej & Boyce Complex,Gate No.4, Plant No.12,LBS Marg, Vikhroli (W),Mumbai-400079. NOT TO BE SENT TO NEW INDIA ASSURANCE COMPANY . Employee should retain scan or photo copies of all the documents . Employee should be able to produce the scan or photo copies of all documents if/ when required. DECLARATION I hereby confirm that the documents submitted by me in support of my above claim are true and genuine in every respect , if the said documents are found to be fraudulent / fabricated/ tampered , then I shall be liable for appropriate disciplinary action by the Company Signature of the Claimant*

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Page 1: DomiForm_100984292_Sanjeev Tayal

DOMICILIARY CLAIM FORMThe New India Assurance Co Ltd Account: Tata Consultancy Services Limited

TATA CONSULTANCY SERVICES LIMITED THE NEW INDIA ASSURANCE COMPANY LIMITED

CLAIM NO:100984292 REGD HEAD OFFICE:NEW INDIA ASSURANCEBUILDING87 MAHATMA GANDHI ROAD,FORT,MUMBAI 400 001

CLAIM DATE:31-03-2012 GROUP HEALTH INSURANCE POLICY NO:121400/34/11/23/00000140

EMPLOYEE DETAILSEmployee Code: 320875 Name: Sanjeev Tayal

PATIENT DETAILSClaim Submitted Date: 31-03-2012

Alpha Code: A Patients's Name: Sanjeev Tayal

Relationship: Self Ailment Details: Dental

Illness Period: From:18-03-2012 To: 31-03-2012

SUMMARY OF EXPENSESNature of Expenses No of Documents Amount(Rs)

Consultation / Prescriptions 2 1200

Diagnostics / Lab tests 1 500

Total: 3 1700

SUPPORTING DOCUMENT-> Original doctors bills & receipts which are numbered & printed

-> Original chemists bills & receipts supported with proper prescriptions

Please submit the claims documents duly stapled in the following manner to avoid misplacement and enableproper verifications. Order should be .

1.Claim form .

2.Doctor's prescription: This must contain the Nature of ailment, Line of treatment and period of treatment withdetails of medicines dispensed or prescribed to the Patient. A prescription should not contain payment details)

3.Proper official, numbered doctor's bill from doctor's bill book (should be original).

4.Cash memos for medicines properly arranged if purchased from chemist with prescriptions (should beoriginal).

5.Copies of all LAB and other test reports if applicable and claimed towards same.

Also, please note that bills / receipts issued on doctor's letter head will not be acceptable for processing theclaim

These documents arranged serially as mentioned above while submitting will help in easy and smoothprocessing of claims.

==============================================================

Documents along with dully filled claim form can be dropped in the drop box in your / nearest locations.

Or alternately documents can be sent to any of the below (nearest) address.

Kolkata Mumbai

HIS team (Kolkata) Tata Consultancy Services 1W-16,1st Floor,Delta Park Eden,Salt Lake ElectronicsComplex,Kolkata - 700 091,WestBengal,India.:100984292

Corporate HIS Team Tata Consultancy ServicesLtd.Wellspring,Desk No.10D-85,Godrej & BoyceComplex,Gate No.4, Plant No.12,LBS Marg, Vikhroli(W),Mumbai-400079.

NOT TO BE SENT TO NEW INDIA ASSURANCE COMPANY.

Employee should retain scan or photo copies of all the documents .

Employee should be able to produce the scan or photo copies of all documents if/ when required.

DECLARATIONI hereby confirm that the documents submitted by me in support of my above claim are true and genuine inevery respect , if the said documents are found to be fraudulent / fabricated/ tampered , then I shall be liablefor appropriate disciplinary action by the Company

Signature of the Claimant*