{"id":2293,"title":"BoB Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/BoB%20Claim%20Form.pdf","sha256":"03a2e90f76d4b1accec0aa40df9f8a78d80aa4130da3ed081ed39d3a75462467","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used to claim health insurance benefits under the BoB National Health Policy. It is filled by the insured/patient and the hospital/treating doctor.","notes":["Fill form in block letters","Use dd-mm-yyyy format for dates and hh:mm format for times","Attach all original bills and documents as per checklist","Page 1 only to be faxed or scanned for cashless hospitalization request","Use original documents only; photocopies must be certified","Keep a copy of the filled form and documents for your records"],"title":"BoB Claim Form","submit":{"to":"TPA / Insurance Company as per policy","how":"post / e-mail / upload as per TPA instructions","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","fields":[{"help":"","type":"text","label":"Name of TPA / Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free phone number","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free Fax","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of the Patient Admitted","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Phone number of patient or insured","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Current address of insured person","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation of insured person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured card ID number","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number or corporate name","type":"text","label":"Policy number / Name of corporate","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Hospitalization Details","fields":[{"help":"Full name of hospital","type":"text","label":"Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Full postal address of hospital","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ROHINI ID","options":[],"required":false,"pdf_field":""},{"help":"Hospital email address","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of admission","options":[],"required":false,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Expected no. of days in hospital","options":[],"required":false,"pdf_field":""},{"help":"Enter number of ICU days if applicable","type":"number","label":"Days in ICU","options":[],"required":false,"pdf_field":""},{"help":"Specify room type","type":"text","label":"Room Type","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient's Diet","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Expected cost of investigation + diagnostics","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"ICU Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"OT Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Medicines + Consumables + Cost of implants (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"Total amount claimed in INR","type":"amount","label":"Sum Total","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of the Treating Doctor","fields":[{"help":"Full name of doctor","type":"text","label":"Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's phone number","type":"phone","label":"Contact number","options":[],"required":false,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Registration No. with state code","options":[],"required":false,"pdf_field":""},{"help":"Preliminary diagnosis","type":"text","label":"Provisional diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Describe illness and symptoms","type":"text","label":"Nature of illness/ disease with presenting complaints","options":[],"required":false,"pdf_field":""},{"help":"Number of days patient has been ill","type":"number","label":"Duration of the present ailment (days)","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of first consultation","options":[],"required":false,"pdf_field":""},{"help":"Specify month and year","type":"text","label":"If Yes, since (month/year)","options":[],"required":false,"pdf_field":""},{"help":"Tick appropriate treatment type","type":"choice","label":"Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive Care","Investigation"],"required":false,"pdf_field":""},{"help":"Name of surgery if applicable","type":"text","label":"If Surgical, name of surgery","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 diagnosis code","type":"text","label":"ICD 10 Code (if any)","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 procedure code","type":"text","label":"ICD 10 PCS Code","options":[],"required":false,"pdf_field":""},{"help":"Describe other treatments if any","type":"text","label":"If other treatments, provide details","options":[],"required":false,"pdf_field":""},{"help":"Specify route (oral, IV, etc.)","type":"text","label":"Route of drug administration","options":[],"required":false,"pdf_field":""},{"help":"Specify AYUSH treatment details","type":"text","label":"Past history of AYUSH Treatment (Please Specify)","options":[],"required":false,"pdf_field":""},{"help":"Phone number of relative attending patient","type":"phone","label":"Contact number of attending relative","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Accident and Injury Details","fields":[{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of injury","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"First Information Report number","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury / Disease caused due to substance abuse / alcohol consumption","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach test reports if yes","type":"yes-no","label":"Test conducted to establish this? (If yes attach reports)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Describe cause of injury","type":"text","label":"How did the injury occur?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Other Medical Insurance Details","fields":[{"help":"Name of other insurance company","type":"text","label":"Company Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Previously covered by any other Mediclaim/ Health Insurance","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Name of previous insurance company","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Claim","fields":[{"help":"Enter claimed amounts in INR","type":"amount","label":"Details of expenses","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for Day Care Procedure","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for Organ Donor’s Medical Expenses","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for HIV/ AIDS Treatment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for Mental Illness Treatment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for Refractive Error","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for Morbid Obesity","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, name of treatment","type":"yes-no","label":"Claim for Modern Treatment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Maternity Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Claim for Hazardous Sport","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Ambulance Charges","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Bills Enclosed","fields":[{"help":"Number of pharmacy bills enclosed","type":"number","label":"Pharmacy Bills","options":[],"required":false,"pdf_field":""},{"help":"Specify other bills enclosed","type":"text","label":"Others","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Name of bank branch","type":"text","label":"Bank Branch","options":[],"required":false,"pdf_field":""},{"help":"Name of beneficiary for cheque/DD","type":"text","label":"Cheque/ DD Payable details","options":[],"required":false,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Declaration by the Insured","fields":[{"help":"Date of signing (dd/mm/yyyy)","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Declaration by the Hospital","fields":[{"help":"Full name of hospital","type":"text","label":"Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Hospital identification number","type":"text","label":"Hospital ID","options":[],"required":false,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Type of Hospital","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address of the hospital","options":[],"required":true,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"Registration No. with State Code","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number of hospital","type":"text","label":"Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Number of beds available","type":"number","label":"Number of inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Full name of doctor","type":"text","label":"Name of treating doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Status at time of discharge","options":["Discharged to home","Discharged to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Total amount claimed in INR","type":"amount","label":"Total claimed amount","options":[],"required":false,"pdf_field":""},{"help":"Date of signing (dd/mm/yyyy)","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge"],"applies_to":"health insurance claims under BoB National Health Policy","attachments":["Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests","Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured","Copy of photo ID card of patient verified by hospital","MLC report & Police FIR (if applicable)","Investigation reports (including CT / MRI / USG / HPE)","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip"],"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 material fact is made, the right to claim reimbursement shall be forfeited","Consent and authorize TPA / insurance company to seek necessary medical information from any hospital or medical practitioner","All bills and receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claims","Hospital confirms no additional amount will be collected from insured beyond agreed package rates except non-admissible amounts","Hospital agrees to provide clarifications for queries and takes responsibility for any delay","Patient agrees to allow hospital to submit all original documents to insurer/TPA after discharge","Payment to hospital governed by terms and conditions of the policy; patient undertakes to settle bill if insurer/TPA is not liable","Patient agrees to pay all non-medical expenses and amounts over authorized limits","Patient declares to abide by policy terms and indemnify insurer/TPA if facts are false or incorrect","TPA is not guaranteeing quality or standard of hospital services","Hospital and patient declarations must be signed in presence of each other"],"dropped_labels":11},"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/national-insurance/2293-bob-claim-form"}