THE ORIENTAL INSURANCE COMPANY LIMITED

TPA-Medi Assist India Pvt Ltd

B-20, Sector - 2, Near Noida Sector 15 Metro Station,

Noida, U.P – 201301

Phone No—120-4628237

HCL INFOSYSTEMS LTD - Domiciliary Claim Form

1. Claim Number (for Medi Assist Use)

2. Policy Number

3. Employee ID Number

4. Employee Name

5. MAID No.

6. (a) Name Of Claimant ( in respect of whom the

claim is made)

(b) Relationship to the Employee

(c ) Present completed age

(d) Occupation

(e) Residential Address

(f) e-mail ID

(g) Contact No- (landline / Mob)

7. Nature of disease/illness contracted or injury

suffered or complete diagnosis

8. Details of Domiciliary Hospitalisation

(a) Date of Commencement of treatment

(b) Date of Completion of Treatment

(c ) Name and Address of Attending Medical

Practitioner

(d) Telephone No.

(e) Registration No.

9. Schedule of Expenses incurred by the claimant under domiciliary claims (to be supported by Original

Bills/cash receipts, Cash memos, etc.)

Pharmacy/ Medicine

Expenses

Consultation

Expenses

Investigations

Expenses

Total Expenses

Domiciliary

Hospitalisation

Benefit

I hereby declare that the foregoing statements are true in every respect and are made without any

reservation. I also declare that I do not get nor I am likely to get any medical benefits for the above illness

from any other source. I consent and authorized the insurers / TPA to seek medical information from any

hospital/medical practitioner who has at any time attended concerning the claim.

Date: Signature of Claimant