icici @Lombard Aapka Plan B CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE (The issuance of this form is not to be taken as an Admission of Liability) (Address to dispatch Claim Documents : Icicl Lombard Health Care Ioicl Bank Tower, Plot No.12, Financial District, Nanakram Guda, ! Cover Note / Policy No Period of Insurance Date of Accident Claim Number Gachibowli, Hyderabad, Andhra Pradesh, PIN No, 600032, PLEASE ANSWER ALL QUESTIONS FULLY 1. DETAILS OF INSURED () Name (i) Address HN. Land mark: State: Contact/ Mobile No: | () Name JJ III JI JJ J J J J J Ju J J J J J J J J (i Address. HN. Land mark State Contact Mobi No: J (iy Age (u) Date & time of injuryeath (vi) Place of nur/ death JJ JI (vi Detaled Description ofthe accident3. Was the inured deceased person shifted to hospital immediately after the accident? | Yes _| No Iryes, Name & address ofthe hospital) J JJ JJ ISIS J Jj JJ Jj jj) 4 Do youhave any ther Personal Accident Policy? Iryes, please give : {i) Adéross ofthe issuing otic: ) J J) J Ai PolcyNo: | J J J J J J Declaration hereby agree affim and declare that {a} Thestatements/nfermation given/stated by me/us inthis claimform are rue, correctand complete. {0} Nomateria information which is relevant tothe processing ofthe claim or which in any manner has @ bearing onthe claim has been withheld ornotdisclosed. {c) Hf thave given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner failed to disclose ‘material information, the policy shall be void and that! shallot be entitled to alVany rights to recover thereunder in respect of any oral claims, past, prasent or futuro. {4} The receipt ofthis claim form/athersupporting/elated documents does nat constitute orbe deemed to constitute an agreement bythe Company of the claim and the Company reserves the right to processor reject or require further/addtional information in respect ofthe claim, Place: J J jj Date: 0 Signature ofthe Injured Person {To be filled in by the Employer/insured) 1. Was the inured person in respect of whom claim being made absent from work? Yes) No) H so, please furish the details of such absence: Leave From: 0) 0) ni) iJ YJ YJ YJ YJ 0 ojos MM) s¥J YJ ¥) 1 We hereby declare thatthe particulars made by the injured person inthe claim from are true to the best of our knowledge and belie. Pace: ) | jj J vate; 9) 0} / ui) YJ ue nature of tensed‘SECTION II (TO BE COMPLETED BY HOSPITAL AUTHORITIES) 1 Nemeandadtessotterossid? JJ J J J I JIS IIIS JJ JJ JI 55533555555 555555555 55555555555 2 Dateof admission: 0) o) fmm) # VJWJYJ {Asin patent outpatient /emergency case) 3. Dateof discharge: 0) 0) smi) ¢ YJ VJ YJ) snetweofinuy: J J J) JJ JJ III IJ IJIJJIIIIIIJIJIIJIII III I (i) Particulars of treatment: | a JJ) J J J J J J J J J J J J J J i) Wot sro Tempo Towloisbind: |) ) J J) J ‘Advised rest unfit work for specified from: oJ 0) FJ) # yy) yy) umber od we ojo} Suu) Fv} VY) Fitness Date join Dts Do) smu) s vJvI YY) ‘5. (i) Has the accident resulted into loss of hand/s or foot/feet or eye/s or permanent disability of anyother type which may prevent the insured from engaging in or being occupied with or giving attention to any employment or occupation whatsoever? ves} No) (i tyes, pleasegivedetails: ) | ) } J | ) | Jj) J) j)) J) Jj) jj) J JJ JJ) J J J) J J J J J J Signature of the competent Authority of treating Hospital / Nursing Home Date: oJ 0) fmm) 7 viv) yyy Name: J Official Seal ofthe Hospital: DesignationSECTION II (TO BE COMPLETED BY NOMINEE IN THE EVENT OF INSURED'S DEATH) 1. Details of Nominee (i) FulName >) (i) Adress (ii) Age (v) Relationship with the deceased J J Date: 0).0J ¢ WJM) ¢ Y} VJ ¥) ¥) ce: J J J J JJ Jj jj Signature ofthe Nominee Dettrationto be signedby the Insured aimantor byte Nominee nthe eventot insureds death WE HEREBY DECLARE and warrant the truth of the foregoing particulars in every respect. I/ We agree that / we have made or shall make false or untrue statement, suppression or concealment, my/our ight to compensation shallbe forfeited, \Vwe also here by declare that | am /we are accepting the amount in full discharge of you obligations under the policy tothe Insured Person and /or his/her legal heirs, (We wllheld youindernifedin the event of any claim under ths policy being made against you by any other person or persons. Date 7 a Jy) pace: J) J J JJ J JJ) Signa ofthe Nanos DIRE Risa enc {A} Wouldyou ike tot for lector Fund Trarsferas mode ofpayent? aves O eno] B) Ifyes, kindly provide the below mentioned details + Payee Name (renters: CI IOOOOOOOOOOOO0 0000000 00000000 + Payee Account Ne: CTT TT TT IDIOUOOIO OOOO + Typeof Account: — [}Savings [] current C] others seein: CILIOIOIOOIOOOOOOOO00000000 + Name of the Bank CTT TTT IDOI + BranchiWame: TTT TT TOO + Address of the Bank: [TT TTT TOU GOO IFSC Code No. ofthe Bank: CCT CIO MICR Code No. of te Bank: CTT TT OOOO + Permanent Account Number (PAN) of Payee: TIO eee‘Terms and Contitions for Payments through RTGS /NEFT. 1. The datas rove by the Customers inte Mandate Frm sl be conieed a fn nd IC Lobaré Goer surance Company Li, sal no be respons cross ‘verfetn fen otha deta provdesteen 2, The ATGS/NEFTTaclty shal bo aleve orth respective Customers) within S dye oft tent ofthe Mans Form by Kl Lonbard Ganarallsuane Company. and! orthinsucheriodas ay bereeonsoy reqiadby Il Lambo Gna eure Company activate th ATES NEF chy, {4 Th Custer ages that unt ATCS/ NEF ay, thre maybe arsk nan peymentin the Acuna Customer on te dy of he crit of Payments du to change inthe saps rstions pertaningoRTGS/NEFT ln os ony oharroson thot ary nacional LonbardGonlsuranee Company asa: beyonéte carl ot CC Lemar Geneallsuanc Company Lined 4 ThaCustamar ages onde, what ly r dour ll Lombard Gaal nsrance Conny Li. nits gets and ee el Lombard Ganrallsrance Company Li and itsapntndomnifedhariesatallimestor ard gant any and alin, amagos losses, cots ard exposes (reusing atone ess wich Il Lombard Gere Inecanos Company. may ser arno, rect rnd arkngomarincomecton ith ang etethngs theft alerts restos stein above lace, 5, [I LombardGenralinsrace Company ida sob-contact an mle agro cyt ny ots cbgations wet ATGS/ NEF ait The Cstorr ay soni” mint tn use of TGS /NEFTcltyy ging arin of 15 dys por rite rate eI Lombard Garralrsrace Company Thats cfotie rl Lambaré wt bathecate of ecoptat such nies byte Lombard Thenatie af such enna shoe gets Laat ony a ts expat des and be asesseé at EE Lard {ICL ct LontardHouse Ol Tatars Bling 414, Vo: Savrkar Mar Near ih Vey Temple, Praha Murba'-A00025 5. Acerfrrutan te ecepttteminaton nie given byte Customer wl be acknowledged tough confi teh ICI embard General surance Company Ln cae can he Cstamer cant is emndtan note sb lective ues a anfemation as. Been rd by IC Lomb the Customer tg the dle of capt ol sch cammuriatonyhaCustemat, 1. MheClsteme ares tat ansacton(s tough ATS/ HEFT fait may tectinwarRTGS/NEFTehrges, hrf levedby the Customers bank, shal beberney te Custer {ICL Lamba has th abso scrton tard o supplement any Terms ané Condor tate hare at ny and wi eave tg tr tice! Ton ays fr such changes wherever ease forth toms and conins to eps. By using there sees, eth camplion af suth prog whichever etl te Cstoma shale Submission ofdecamsns rbark état ran athriferation oes rtinany way shape orfarm npr xpressor suggest dmssont abit compary. Notcus under these tems aod cans may be Quen i ming by delving then by hand er ema ton I! Lanbard General Iauence Company Ld, webste clombaszom arby sending thom pestiote stadoss th Customs Thesstemsand cords wb govanedby telus fleas ealaction proceedings arcing out these Terms and Cartons sallbsinatedinthcoutsoribunls sthurosinind UWelurher undertake tren ary excess anovrt wheter demanded by IC Lonard Generllsuance Company Ld. ona which has beancretedinercess tony account st any ime de tay esan within 1 day a uch eet sun com™uneata rom IT Lanta sch exes ede Such uration ol excas ead coming the ‘rolgeothe Customs: Brough ay ar sort 12. We agree that yar ir payment wil credited fe tha ate EC Lombard General surance Cagany Ls. geecnfomaion am ts bakers Tifa wll arte ‘alas revted yay pity and at stance of olan cad sraon om Il Lombard Gare sane Capany Ld toisbarkas wile valtiaueh istrcons ‘ample spective otha tate notion parade exped rove sich credtequsthas been dey Lamar Geel surance Camany i eee tera ‘henaticeperad afta Customa ‘Signature ofthe Account lder icici GLombard Aapka Plan B Aap, 1 ik oi, ene oo, an at Mata oe ted to eo Sosa er Vo nl abate, ms ots wodanarom Val hula iceman orzasscr/sc