{"id":134,"title":"HEALTH INSURANCE CLAIM FORM","purpose":"claim","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/future-aarogya-bima/claim-forms/aarogya-bima-claim-form.pdf","sha256":"90b48c8a75e25513bdc16e09863cbacb75f01ef1e9a23a0ec963139cbeb0b52f","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured individual or claimant to submit a health insurance claim to Generali Central Insurance Company Limited.","notes":["All fields in this form are mandatory.","Use original bills only, with pre-numbered receipts signed and stamped.","Attach a photocopy of the Health ID Card.","Attach a photocopy of a cancelled cheque for NEFT details.","Separate claim form required for each claim.","Please attach this form in original to the hospital bill and other claim documents.","HR authorization and bank authorization stamps are mandatory in certain cases as specified."],"title":"HEALTH INSURANCE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"POLICY / INSURED DETAILS","fields":[{"help":"","type":"text","label":"Name of the Employee / Individual:","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"E-Mail address of the Employee/Individual:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number :","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Permanent Account Number (PAN):","options":[],"required":true,"pdf_field":""},{"help":"Enter Aadhar number","type":"text","label":"Aadhar Card No :","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder / claimant"},{"title":"CLAIMANT / PATIENT DETAILS","fields":[{"help":"","type":"text","label":"Name of the Patient:","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"Relationship with the Employee / Proposer","options":["Self","Spouse","Child","Parent","Others"],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth of Claimant:","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age  Years","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Full address","type":"text","label":"Residential Address","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"CLAIM DETAILS","fields":[{"help":"Write amount in words","type":"text","label":"Claimed Amount in Words: Rupees","options":[],"required":true,"pdf_field":""},{"help":"Medical diagnosis","type":"text","label":"Diagnosis","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Admission Date:","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Discharge Date :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Treating Doctor:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No. of Treating Doctor:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Family Physician:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No. of Family Physician:","options":[],"required":true,"pdf_field":""},{"help":"List other health policies if any","type":"text","label":"Details of other existing Health Policies:","options":[],"required":true,"pdf_field":""},{"help":"List current medications","type":"text","label":"Ongoing Medication :","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"ENCL0SURE CHECK LIST","fields":[{"help":"Attach all listed documents","type":"checkbox","label":"Enclosure Check List","options":["Original discharge summary containing all relevant details","All original bills and their pre-numbered receipts duly signed with a revenue stamp","Copies of all reports & prescriptions","First prescription / consultation letter from your Doctor","Copy of proposer/employee photo id & address proof","NEFT Form with photocopy of cancelled cheque with printed name of proposer / employee"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"CONSENT","fields":[{"help":"","type":"text","label":"Name of Patient / Relative:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Patient:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Patient / Relative:","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"patient or relative"},{"title":"POLICY AND CLAIM DETAILS","fields":[{"help":"","type":"text","label":"Claim Number (If Available):","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Health Card No. of Patient","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Policy Start Date","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Policy End Date","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Joining the Policy","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Corporate Name : (Only for Group Policies)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Employee ID","options":[],"required":false,"pdf_field":""},{"help":"Enter total claim amount","type":"amount","label":"Total Claimed Amount:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"AUTHORIZATION FOR TRANSFER OF CLAIM AMOUNT BY NATIONAL ELECTRONIC FUND TRANSFER","fields":[{"help":"Name on bank account","type":"text","label":"Name as per Bank Account","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Name & Address","options":[],"required":true,"pdf_field":""},{"help":"MICR code of branch","type":"text","label":"Branch MICR Code","options":[],"required":true,"pdf_field":""},{"help":"IFSC code for NEFT","type":"text","label":"Branch IFSC Code for NEFT","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type (Please Tick)","options":["Saving","Current","Cash / Credit"],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No. (as appearing in Cheque Book)","options":[],"required":true,"pdf_field":""},{"help":"Attach HR authorization and stamp if applicable","type":"attachment","label":"HR Authorization & Stamp (Mandatory for Group Policies in case cheque or passbook copy not available)","options":[],"required":false,"pdf_field":""},{"help":"Attach bank authorization and stamp if applicable","type":"attachment","label":"Bank Authorization & Stamp (Mandatory for Retail Policies in case cheque or passbook copy not available)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Employee / Proposer:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Employee / Proposer:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Claimant Name:","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"FEEDBACK AND SUGGESTIONS","fields":[{"help":"Write your feedback or suggestions","type":"text","label":"Feedback and Suggestions","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"","attachments":["Original discharge summary containing all relevant details","All original bills and their pre-numbered receipts duly signed with a revenue stamp","Copies of all reports & prescriptions","First prescription / consultation letter from your Doctor","Copy of proposer/employee photo id & address proof","NEFT Form with photocopy of cancelled cheque with printed name of proposer / employee","Photocopy of the Health ID Card","Photocopy of a cheque or a blank cheque of your bank duly cancelled"],"declarations":["I authorize Generali Central Insurance Company Limited or its authorized agents to obtain and review all my medical records related to this claim.","I agree that all information provided in the claim documents is true and that any false information will forfeit my right to claim reimbursement.","I declare that the bank details provided are correct and request remittance of any amount due to the specified bank account.","I agree that the company is not responsible for delays or errors in transaction due to incorrect or incomplete bank information.","I undertake to advise any change in bank account details to facilitate credit of any amount due."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"GCIcare@generalicentral.com","label":"Claim Intimation Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"ses.\nCLAIM FORM\nYou can\nclick here\nand check our claim form\nCALL ON\n1800 220233\n1860 500 3333\n022 6783 7800\nEMAIL US AT\nGCIcare@generalicentral.com\nVISIT OUR BRANCH\nYou can check for your nearest branch\nhere\nClaim Process Simplified\nSimple steps to help you file a cl","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"GCIClaims@generalicentral.com","label":"Other Claim Intimation Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/other-claim-process","quote":"NLINE CLAIM INTIMATION\nYou can\nclick here\nto intimate claim\nCALL ON\n1800 220233\n1860 500 3333\n022 6783 7800\nEMAIL US AT\nGCIClaims@generalicentral.com\nVISIT OUR BRANCH\nYou can check for your nearest branch\nhere\nInitiate Quick Claim\nExtended Warranty\nMarine & Others\nProd","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 220 233","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"aim under your insurance policy.\nCashless Claim Process\nReimbursement Claim Process\n1\nIntimate us online or  Call us on 1800 220 233\n2\nSurveyor will inspect the vehicle.\n3\nProvide requested documents to surveyor\n4\nApproved claim amount will be communic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1860 500 3333","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"Motor Claim Process | Generali Central\nGrievance Redressal\nQuick Pay\nNeed Analysis\n1860 500 3333\n|\n022 6783 7800\n1860 500 3333\n022 6783 7800\nProducts\nRenew\nClaim\nHelp & Support\nAbout Us\nTrending Searches\nHealth Insur","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 6783 7800","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"Motor Claim Process | Generali Central\nGrievance Redressal\nQuick Pay\nNeed Analysis\n1860 500 3333\n|\n022 6783 7800\n1860 500 3333\n022 6783 7800\nProducts\nRenew\nClaim\nHelp & Support\nAbout Us\nTrending Searches\nHealth Insurance\nDog Insuran","fetched_at":"2026-10-20"}],"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/generali-central-insurance/134-health-insurance-claim-form"}