Claim No.

: __________________

RELIANCE HEALTHWISE POLICY, RELIANCE HEALTHGAIN POLICY AND GROUP MEDICLAIM - CLAIM FORM

(The issuance of this form is not be taken as an admission liability - Please give the following information correctly and completely)

PART A (TO BE FILLED BY INSURED)

1) Type of Claim: Hospitalization Pre & Post Hospitalization Health Check up OPD

2) *Policy No.: Policy Type: Individual Group

Group/Company Name
(for Group Health Policies)
Is this a renewal policy Yes No If Yes, previous year's policy no

Agent/Sub Agent Name

Agent Mobile No. Agent Email ID

3) Details of the Insured Person in respect of whom the claim is made

*Name
Present completed age
Gender: Male Female
(in years)
Relationship with the Policy
*Card / UHID No.
Holder
Sum Insured ₹

*Current Residential Address

City *PIN Code

State
Change of the contact
Yes, I wish to change my contact details There is no change in my contact details
Details
Please update mentioned mobile number as primary contact details against my policy. I also hereby confirm to be contacted on the
number provided below for Claim Status /Policy Renewal.
*Mobile Number

4) Profession/Occupation Business Profession Salary Agricultural Income Savings Others

5) Monthly Income Upto ₹ 20,000 ₹ 20,001 to ₹ 50,000 ₹ 50,001 to ₹ 1,00,000 ₹ 1,00,001 and above

6) PAN No.
7) Name of the Policy Holder
(Self / Main Member)
*Email ID
*Member ID No. /
Employee ID / Client ID
Yes No
8) Does the claimant have health insurance policy with any other insurance company?
(If yes, please provide the details)
Name of the Insurance
Company
Policy No. Sum Insured ₹

Policy Start Date D D / M M / Y Y Y Y Policy End Date D D / M M / Y Y Y Y

Name of the Insured

reliancegeneral.co.in 022 4890 3009 (Paid) 74004 22200 (WhatsApp)

IRDAI Registration No. 103. Reliance General Insurance Company Limited. An ISO 9001:2015 Certified Company
For complete details on the benefits, coverage, terms & conditions and exclusions, do read the sales brochure, prospectus and policy wordings
carefully before concluding sale. Registered & Corporate Office: 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off.
Western Express Highway, Goregaon (E), Mumbai-400063. Corporate Identity Number: U66603MH2000PLC128300. Trade Logo displayed above
belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Reliance
Reliance HealthGain
HealthGain Policy.
Policy. UIN: UIN: RELHLIP13001V011213.
RELHLIP13001V011213. Reliance HealthWise Reliance HealthWise Policy.Group
Policy. UNI: RELHLIP06001V010506. UNI:Mediclaim.
RELHLIP06001V010506. Group
UIN: RELHLGP02001V010102. Mediclaim. UIN: RELHLGP02001V010102.
RGI/MCOM/CO/COMMON-HEALTH CLAIM FORM/VER.1.0/070324.
 9) Hospitalization Detail

Date of Admission D D / M M / Y Y Y Y Date of Discharge D D / M M / Y Y Y Y

Diagnosis / Nature of disease / illness contracted / injury
suffered
10) Date of injury sustained
or disease / illness first
detected
11) Details of the Hospital / Nursing Home in which treatment was taken:
Name of the Hospital /
Nursing Home
Address of the Hospital /
Nursing Home
City PIN Code

State Telephone / Mobile Number

Registration Number
12) Name of Treating Physician/
Surgeon
Qualification Registration Number

Telephone / Mobile Number PIN Code

13) Details of the amount claimed
Bill Heads Amount /(In ₹) Bill Number Bill Date Bills attached

A Room Rent & Nursing Charges DD/MM/YYYY Yes No

B Doctors Consultation/Visit Charges DD/MM/YYYY Yes No

Investigation Charges(Includes Radiology
C DD/MM/YYYY Yes No
and Pathology Reports)
D Surgeon and Asst. Surgeon Charges DD/MM/YYYY Yes No

E Anesthetist Charges DD/MM/YYYY Yes No

F Operation Theater Charges DD/MM/YYYY Yes No

Medicine Charges (Includes Ward and
G DD/MM/YYYY Yes No
OT Medicines and Consumables)
H Taxes/Surcharges/Service Charge DD/MM/YYYY Yes No
Miscellaneous/Other Charges
I DD/MM/YYYY Yes No
(like Admission, Registration, etc.)
J Pre Hospitalization Bills (If Any) DD/MM/YYYY Yes No

K Post Hospitalization Bills (If Any) DD/MM/YYYY Yes No

Total Claimed Amount (Sum of A to K) DD/MM/YYYY Yes No

In support of the above claim, I enclose following documents in original (Please indicate by ticking the o Yes o No)
Claim form Duly Filled Yes No Investigation Reports/Reports Name Yes No
Medicine/Pharmacy Bills with Doctors
Authorization Form Yes No Yes No
Prescription
Discharge Summary Yes No Implant Name and Invoice (If any) Yes No

Hospital Bills Yes No Indoor Case Papers (duplicate copy) Yes No

Hospital Payment Receipt Yes No Others Yes No

Photo Identity Proof Yes No

Total No. of Pages enclosed

As per the policy terms and conditions, the Company reserves its right to have the Insured examined by a doctor appointed by it for
verification of diagnosis.
Please note: In case the Health Gain Policy under which the claims is being lodged has been taken on instalment basis then in the event

Reliance HealthGain Policy. UIN: RELHLIP13001V011213. Reliance HealthWise Policy. UNI: RELHLIP06001V010506. Group Mediclaim. UIN: RELHLGP02001V010102.
 of claim being admissible, the company will deduct the balance instalments due if any, from the claim approved amount and pay
the balance due to the Policyholder. In the event of the claim assessed amount being lower than the Balance instalment due then the
Policyholder is liable to pay the balance premium instalments due immediately by cheque or DD, failing which the said Claim would be
treated as inadmissible and the Policy shall stand cancelled immediately and no liability shall be admissible under the Policy for any Claims
liability in future or in period elapsed.
Any hospitalization from the notified Hospital will not be entertained. please refer the notified hospital list on our website:
www.reliancegeneral.co.in

POLICYHOLDER BANK DETAILS

14. Name of the Bank Account
Mr. Mrs. Ms. F I R S T M I D D L E L A S T
Holder
15. Bank Account No.: 16. Account: Saving Current

17. Name of the Bank

18. Branch
19. MICR Code (9 digit MICR code number of the bank and branch
appearing on the cheque issued by the bank)
20. IFSC Code (11 character code appearing on your cheque leaf)
I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*
*As per IRDAI, its mandatory that all payments made to the insured are only through electronic mode.
Note: Please attach original cancelled cheque and a copy of PAN card for verification of the particulars provided in this regard.

PAYMENT OPTION BY AADHAAR CARD ( FOR REIMBURSEMENT CLAIMS)

Aadhaar Card No.: (Note: Self attested Aadhaar card copy to be submitted)
I wish to collect claim reimbursement directly in my Bank account linked with my aforementioned Aadhaar Card. I understand that the
claim amount shall be credited directly in my latest Bank account linked with my Aadhaar Card.
I/We hereby declare that the details given above are true and correct to the best of my belief and knowledge. In the event above information
or any part thereof is found incorrect, I agree that all right under the policy will be forefeited.I agree to provide additional information to
the Company if required. I will indemnify and hold harmless the Company due to any loss arising out of misstatement in this form and am
willing if required, to make a statutory Declaration before a Justice of the Peace of the truth of the whole of the foregoing statement or any
other statement I may make in connection with this claim.
I further agree and undertake not to receive from Reliance General Insurance Company Limited any rebate other than that mentioned in the
published prospectus in accordance with the provisions Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment)
Act, 2015.

Date: ____________________________ ____________________________________

Place: ___________________________ (Signature of Claimant)

PART B - TO BE FILLED BY THE TREATING DOCTOR (This section is mandatory only if your health policy was not provided by your
employer)
A) Date of First Consultation (Prior to Hospitalization)

B) With what complaints was the patient admitted for

C) Detail history of past illness with duration

D) Whether the present ailment is a compilations of Pre-Existing disease?

E) If, yes please specify the disease (OR) complication of any previous surgery done?

F) Whether the disease / disorder is congenital in nature?

G) If yes please specify the details

H) Nature of surgery / treatment given for present ailment

I) Number of in-patient beds in the hospital (including ICU)

Date: ____________________________ ____________________________________

Place: ___________________________ (Doctor's Seal and Signature)

Reliance HealthGain Policy. UIN: RELHLIP13001V011213. Reliance HealthWise Policy. UNI: RELHLIP06001V010506. Group Mediclaim. UIN: RELHLGP02001V010102.
 TERMS AND CONDITIONS FOR PAYMENTS THROUGH RTGS/NEFT
1. The details provided by the Customers in the Mandate form shall be considered as final and Reliance General Insurance Company Ltd.
Shall not be responsible for cross verification of any of the details provided therein.
2. The RTGS/NEFT facility shall be effective for the respective customer(s) within 15 days of the receipt of the Mandate form by Reliance
General Insurance Company Ltd. and/or within such period as may be reasonably required by Reliance General Insurance Company
Ltd. to activate the RTGS/NEFT facility.
3. The Customer agrees that under the RTGS/NEFT facility, there may be a risk of non-payment in the account of customer on the day of
the credit of payments due to change in the applicable regulations pertaining to RTGS/NEFT facility or due to any other reasons without
any fault/inaction/failure on part of Reliance General Insurance Company Ltd or any factor beyond the control of Reliance General
Insurance Company Ltd.
4. The customer agrees to indemnify, without delay or demur, Reliance General Insurance Company Ltd and its agents and keep Reliance
General Insurance Company Ltd and its agent indemnified harmless at all times from and against any and all claims, damages, losses,
costs, and expenses (including attorney's fees) which Reliance General Insurance Company Ltd may suffer or incur, directly or indirectly,
arising from or in connection with, amongst other things, either of the aforesaid reasons stated in above clauses.
5. The Customer May discontinue or terminate the use of RTGS/NEFT facility by giving a minimum of 15 days prior written notice to
Reliance General Insurance Company Ltd. The date of notice will be considered from the date of receipt of such notice by Reliance
General Insurance Company Ltd. The notice of, such termination should be given to Reliance General Insurance Company Ltd. only at
its corporate address and be addressed at Reliance General Insurance Company Limited, Reliance Centre, South Wing, 4th Floor, Off.
Western Express Highway, Santacruz (East), Mumbai - 400 055.
6. A Confirmation of the receipt of termination notice given by the customer will be acknowledge through a confirmation Letter by Reliance
General Insurance Company Ltd. In no case can be the customer construe his termination notice as effective unless a confirmation
has been provided by Reliance General Insurance to the customer stating the date of Receipt of such communication by the customer.
7. The Customer agrees that transaction(s) through RTGS/NEFT may attract inward RTGS/NEFT charges, which if levied by the customer's
bank, shall be borne by the customer.
8. Reliance General Insurance has the absolute discretion to amend or supplement any Terms and Condition stated herein at any time
and will endeavor to give prior notice of Ten days for such changes wherever feasible for the terms and conditions to be applicable. By
using the new services, or at the completion of such period, whichever is earlier, the Customer shall be deemed to have accepted the
changed terms and conditions.
9. NEFT facility for group policy holder shall be done at the consent of HR.
10. Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or on Reliance General
Insurance Company Ltd. website www.reliancegeneral.co.in or by sending them by post to the last address of the Customer.
11. These terms and conditions will be governed by the laws of India and any legal action or proceedings arising out of these Terms and
Conditions shall be initiated in the courts or tribunals at Mumbai in India.
12. I/We further undertake to refund any excess amount whether demanded by Reliance General Insurance Company Limited or not,
which has been credited in excess to my account at any time due to any reason within 7 days of such receipt of such communication
from Reliance General Insurance of such excess credit or such information of excess credit coming to the knowledge of the customer
through any other source.
13. I/We agree that my/our claim payment will be credited from the date Reliance General Insurance Company Ltd. gets confirmation
from its bankers, this facility will continue unless it is revoked by any party and any issuance of relevant credit instruction from Reliance
General Insurance Company Ltd. to its bankers will be valid till such instructions is complete irrespective of the fact that the notice period
has expired provided such a credit request has been made by Reliance General Insurance Company Ltd. before the expiry if the notice
period of the customer.
14. As per IRDAI any claimed amount above 1 lac, Copy of PAN Card/Form 60 of the insured for corporate reimbursement claim/Proposer
for retail reimbursement claim is mandatory, and below 1lac Photo identity proof (for eg- Aadhar card, Driving license, Election card,
Passport etc) is mandatory.
15. For NEFT settlements to insured/Proposer we require CTS 2010 cheque, CTS 2010 compliant cancelled cheque should have Name of the
Account holder, Account number and IFSC code of the bank to be printed on cheque is mandatory.
16. Inca Non CTS 2010 compliant cheque photocopy of the passbook/bank statement with all the required details (Name of the Account
holder, Account number and IFSC code of the bank should be printed on passbook/bank statement) should be submitted.

Date: ____________________________ ____________________________________

Place: ___________________________ (Signature of the account holder)

* Mandatory details to be filled

Reliance HealthGain Policy. UIN: RELHLIP13001V011213. Reliance HealthWise Policy. UNI: RELHLIP06001V010506. Group Mediclaim. UIN: RELHLGP02001V010102.
 PEP DECLARATION:

Are you a Politically Exposed Person (PEP)? Yes No

If yes, please mention the position held

Is any of your close relation or family member a PEP? Yes No

If yes, please mention the name and relation and the position held
by such close relative/family member.
I hereby declare that in future if me, any of my close relatives or any of my family member attains a position of PEP then I shall confirm the
same to Reliance General Insurance Co. Ltd as a mandate. I understand that this is a crucial information under the PMLA Rules and AML/
CFT Guidelines and shall confirm that the answers given by me is true. In case the company comes to know that this is a misrepresentation
and concealment of information then the policy shall be put on hold for scrutiny by the company and I shall be solely responsible for
the same.
Note :
“Politically Exposed Persons” (PEPs) shall have the meaning assigned to it under sub clause (db) of clause (1) of Rule 2 of the Prevention of
Money Laundering (Maintenance of Records) Rules, 2005.”
(db) “Politically Exposed Persons” (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country,
including the heads of States or Governments, senior politicians, senior government or judicial or military officers, senior executives of state-
owned corporations and important political party officials”.

AML Guidelines
1. I/We hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been /will be paid out of
proceeds of crime related to any of the offense listed in Prevention of Money Laundering Act,2002.
2. I Understand that the Company has the right to call for document to established sources of funds.
3. The Insurance Company has right to cancel the insurance contract in case I am/have been found guilty by competent court of law under
any of the statutes, directly or indirectly governing the prevention of money laundering in India.
Place: ___________________________
Date: ____________________________

________________________________
Signature of Proposer

GENERAL DECLARATION:
I understand that as per the new AML/CFT Guidelines issued Reliance General Insurance Co. Ltd will be verifying my details pertaining to
KYC and PAN provided at the time of proposal.
I further, do hereby agree and consent that in the case of the event of a mismatch of information provided by me in the proposal form,
identification proof, and address proof at the time of issuance of the policy. I request Reliance General Insurance Company Limited to issue
the policy with the details appearing as per my proposal form. I will be solely responsible for any consequences arising out of the difference
in detail given by me during the verification of supporting documents provided by me at the time of issuance of the policy or otherwise.

RCare Address:
Rcare Health: Reliance General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur,
Hyderabad - 500081. Email: healthcare@indusindinsurance.com.

Reliance HealthGain Policy. UIN: RELHLIP13001V011213. Reliance HealthWise Policy. UNI: RELHLIP06001V010506. Group Mediclaim. UIN: RELHLGP02001V010102.