Health Form

Health Claim Intimation

Please fill following and we will contact you at the earliest.

Policy No.
Policy holder
Contact Person
Contact No
Email Address
Employee Name
Patient Name and Relationship with the Employee
Expected Date of Admission
Health Card No.History of Presenting Illness
(exact duration)
History of Presenting Illness
(exact duration)
Date of Admission
Expected length of Stay
Expected cost of the Treatment