{"id":1002,"title":"Claim Form Part-A To Be filled in by the Insured","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/Claim_Form_Part_A_To_Be_filled_in_by_the_Insured_1_5db7a4b4b8.pdf","sha256":"35e6372b8598e124db25e406329d81d49256d3bd28a3d88b761fef49ff195d0d","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to submit a health insurance claim. The insured fills in personal, insurance, hospitalization, and claim details.","notes":["Use dd-mm-yy format for dates unless otherwise specified.","Use block letters where applicable.","Include STD code with phone number.","Do not enter paise values in amount fields.","Tick the appropriate options where indicated."],"title":"Claim Form Part-A To Be filled in by the Insured","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number as allotted by the organization","type":"text","label":"SI. No/ Certificate No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID No as per IRDA license and TPA documents","type":"text","label":"Company TPA ID No.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder: Surname, First name, Middle name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address including Street, City and Pin Code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURANCE HISTORY","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Currently covered by any other Mediclaim / Health Insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Commencement of first Insurance without break","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"Company Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured in rupees","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been Hospitalized in the last 4 years","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use mm-yy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Previously Covered by any other Mediclaim/ Health Insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"Company Name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter full name of the patient: Surname, First name, Middle name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option or specify if Others","type":"choice","label":"Relationship to primary Insured","options":["Self","Spouse","Child","Parent","Others"],"required":null,"pdf_field":""},{"help":"Tick the correct option or specify if Others","type":"choice","label":"Occupation","options":["Salaried","Self-employed","Student","Retired","Others"],"required":null,"pdf_field":""},{"help":"Enter full postal address including Street, City and Pin Code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Enter complete e-mail address","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF HOSPITALIZATION","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Room category occupied","options":["General Ward","Semi-Private","Private","ICU","Others"],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Hospitalization due to","options":["Illness","Injury","Maternity","Others"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury/Date Disease first detected/ Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in hh:mm format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in hh:mm format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"If Injury give cause","options":["Accident","Fall","Burn","Others"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter system of medicine used for treatment","type":"text","label":"System of Medicine","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF CLAIM","fields":[{"help":"Enter amount claimed as treatment expenses in rupees (no paise)","type":"amount","label":"Details of Treatment Expenses","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Claim for Domiciliary Hospitalization","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amount claimed as lump sum or cash benefit in rupees (no paise)","type":"amount","label":"Details of Lump sum/ cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick the supporting documents submitted","type":"checkbox","label":"Claim Documents Submitted-Check List","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF BILLS ENCLOSED","fields":[{"help":"List bills enclosed with their amounts in rupees","type":"table","label":"Indicate which bills are enclosed with the amounts in rupees","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax department","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number as allotted by the bank","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of bank and branch","type":"text","label":"Bank Name and Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"Cheque/ DD payable details","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION BY THE INSURED","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["All bills / receipts for the purpose of this claim","MLC Report & Police FIR (if applicable)"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim reimbursement shall be forfeited.","Consent and authorize TPA / insurance company to seek necessary medical information / documents from any hospital / Medical Practitioner who attended the person.","I have included all bills / receipts for this claim and will not make any supplementary claim except pre/post-hospitalization claim, if any."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/oriental-insurance/1002-claim-form-part-a-to-be-filled-in-by-the-insured"}