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*
31-03-2012 05:22