IFFCO-TOKIO GENERAL INSURANCE COMPANY LIMITED

2013/14
MEDICAL CLAIM FORM
Employee Code
Employee Name

83100617
Akshat
Malhotra

Level

Name of Patient/s
Self

Tick appropriate box

Spouse
Child1 Child2

Akshat Malhotra

Claim Particulars
Bill No.
PGCS1302734
186253
CS0095466

Date
28/03/14
28/03/14
25/03/14

Amount
450.00
27.00
82.00

D/H*
D
D
D

Age 27 Years
Address

__Castrol India Ltd,

Employee Status

__Serving Employee

Nature of accident or illness

causing expenses claimed.
(This is mandatory, if not
mentioned claim will be
rejected)

__BP India Services Pvt. Ltd. [please tick]

__Retired Employee

Strain in lower back due to longer working hours spent while

sitting in front of work station. Check-up done in consultation
with the Physiotherapist.
Total Amount
* Please indicate whether bill relates to Domiciliary (D) or
Hospitalisation (H)
I declare that the foregoing statements are true to the best
of my knowledge and belief that the expenses described
above were incurred in the circumstances described in the
form.

Details of expenses incurred

in respect of:
1. Domiciliary Treatment

Rs559.00..

2. Hospitalisation

Rs..

Date:

Signature:

Note: The Insurance Company reserves the full right of acceptance and settlement of all claims under this policy. The company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any Insured Person;. The company is also not liable to make good any difference between the actual expenses incurred by the insured employee and the actual claim settled by the Insurance
Company. You are advised to familiarise yourself with the policy in detail before submitting any claims.