HDFC ERGO General Insurance Company

Limited

HDFC ERGO General Insurance Company Limited Claim Form -

Hospitalisation
(Issuance of this form does not imply acceptance of the liability)
PLEASE ANSWER EVERY QUESTION AND FULLY
1. Employee Details
1) EC # ; 1. 30015301
2) Name of the Employee and 2. DHAVALKUMAR TRIVEDI
3) Date of Joining 3. 23-02-2015
4) Company name 4. ADANI HAZIRA PORT PVT. LTD.
5) Office Location 5. HAZIRA,CHORYASI,SURAT-394270

2. Policy No/UHID 2999202475243800000

3. Type of Claim Main Hospitalization / Pre Post / Cashless obtained
4. Address of the Insured employee Plot SIDDHA Building WESTERN
(Residential) No/Door No. CHAKRA name HEIGHT WING
— B/301
Road PAL ROAD, NR. SAI RACHANA SOC.
Area L P SAVANI ,ADAJAN
City SURAT Pin code 3 9 5 0 0 9
State Gujarat
Phone No.
E-mail Id dhavalkumar.trivedi@adani.com
5.
a) Name of the insured person a. DHAVALKUMAR TRIVEDI
(Patient, in respect of whom b. SELF
the claim is made) c. MALE
b) Relationship to the insured d. 31.3 YRS.
c) Gender e. DANGUE FEVER
d) Present completed age
e) Diagnoses:
6. Date of injury sustained or 07-11-2018
disease/illness first detected

7. Nature of Diseases / Illness FEVER

8. a) Name & address of the DR. SONAL CHAVDA
attending medical practitioner MAHALAXMI SQUARE , 2ND FLOOR, L P SAVANI CIRCLE,
ADAJAN,SURAT- 395009
b) Qualification & telephone no MD(MEDICINE) M(9099951522)

c) Registration no. G-11456

9. Name & address of the hospital/nursing SAI MEDICAL HOSPITAL

home/clinic MAHALAXMI SQUARE , 2ND FLOOR, L P SAVANI CIRCLE,
ADAJAN,SURAT-395009

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HDFC ERGO General Insurance Company
Limited

10. Date of admission with timing 11/11/2018 --11:00

11. Date of discharge with timing 14/11/2018 --20:30

12. If the claim is for domiciliary
hospitalisation, please indicate
a) Date of commencement of a)
treatment
b) Date of completion of treatment b)
c) Name & address of attending
medical practitioner c)
d) Telephone no. NOT APPLICABLE
e) Registration no.
d)
e)
13. Schedule of expenses incurred by the claimant under hospitalisation/domiciliary hospitalisation (to
be supported by bills/receipts, cash memos etc.)
Expenses incurred in the hospital as per statement attached

Amount Claimed (Claim 18802 /----

bill attached)

I have incurred on the treatment of Disease/Illness/Accident referred to above, the expenses as per the
details given by me in the attached claim bill.

In support of the claim, the following documents have to be submitted in original along with the claim
bill.

1. Original Bills, Receipt and discharge certificate from the Hospital.

2. Cash Memos from the hospital / Chemist(s), supported by the proper prescription
3. Receipt and reports with a supported by the note from the attending Medical practioner /
Surgeon demanding such report & test. (Blood, Pathological, Urine, Scan, MRI etc.)
4. Surgeons certificate stating nature of operation performed and Surgeon's bill and receipt.
5. Attending Doctor's / Consultant’s / Specialist's / Anesthetist's bills and receipt and certificate
regarding diagnosis
6. Certificate regarding admission and discharge from the Hospital.
7. Patient's History report from the attending Doctors.
8. Certificate from the attending Medical Practitioner / Surgeon that the Patient is fully cured.
I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or
shall make any false or untrue statement, suppression or concealment, my right to claim reimbursement
of the said expenses shall be absolutely forfeited. I further declare that in respect of the above
treatment, no benefits are admissible under any other Medical Scheme or Insurance.

Date: 03-12-2018 Mobile# 9601286071

Signature of the 61660
Ext No:
Insured

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HDFC ERGO General Insurance Company
Limited

Sr.
No. NEFT DETAILS ( Employee Salary Account)
(Pl. Fill up the form Caps Letters)
1 Name of the Account Holder DHAVALKUMAR BIPINCHANDRA TRIVEDI

2 Bank Name ICICI BANK

Full Bank account number (without /,- or

3 137401506519
any special characters)

4 IFSC Code ICIC0001374

5 Account Type (Saving) SAVING

DAHEJ BRANCH, MARUTI COMPLEX, NR. IBP PETROL

6 Bank Address
PUMP,DIST- BHARUCH (392130)

7 Account Holder Mobile Number 9601286071 / 9099995589

dhavalkumar.trivedi@adani.com ,
8 Account Holder E-Mail ID
dhavaltrivedi91@yahoo.com

9 Employee Code 30015301

Please note that your Mediclaim Settlement amounts will be credited through ECS/RTGS/NEFT in
above Bank account Number.

We here by confirm and declare that above information provided are correct as per our knowledge.
Note: HR-Department please check above details with Employee salary account.

Signature of the of Employee Signature of HR-Dep

Name of Employee Name of HR-Executive