{"id":2307,"title":"Claim Intimation Form","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/claim_intimation_form_insurance-2-","sha256":"7fadf3f40999130ae61050bf0fa53724dc60789ca8106f6417a4a19cfd4d8619","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the policyholder or principal insured to notify the insurer and TPA about a health insurance claim related to hospitalization. It is filled by the policyholder or claimant.","notes":["The form must be filled and signed by the Principal Insured / Policy Holder only","If the Principal Insured is unavailable, the spouse may submit the claim with a declaration explaining the circumstances","Ensure all particulars including policy number, TPA name and card number, beneficiary details, hospital and doctor details, and diagnosis are filled","If patient transfer between hospitals exceeds 12 hours, the second admission is treated as a new admission","Do not submit original x-rays/scan reports; submit copies of prescriptions, bills, and reports only","Communicate with TPA in writing to maintain accurate records"],"title":"Claim Intimation Form","submit":{"to":"Third Party Administrator (TPA)","how":"submit prior to hospital admission unless admitted in emergency; can also be faxed to the fax number provided by the TPA","address":""},"purpose":"claim","sections":[{"title":"Particulars of the Principal Insured (Policy Holder)","fields":[{"help":"","type":"text","label":"Name of the Policy holder / Claimant","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for communication","options":[],"required":true,"pdf_field":""},{"help":"Include STD code and telephone number","type":"phone","label":"Telephone Number (STD Code) (Telephone Number)","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email id","options":[],"required":false,"pdf_field":""}],"filled_by":"Policy Holder / Claimant"},{"title":"Particulars of Third Party administrator","fields":[{"help":"","type":"text","label":"Name of the TPA","options":[],"required":true,"pdf_field":""},{"help":"Unique Health Identification Number given by the TPA","type":"text","label":"UHID Number allotted by TPA","options":[],"required":true,"pdf_field":""}],"filled_by":"Policy Holder / Claimant"},{"title":"Details of the Insured Member for whom the claim is preferred","fields":[{"help":"","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship (e.g. self, spouse, child)","type":"text","label":"Relationship with the Principal Insured","options":[],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Sex","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Present occupation","options":[],"required":false,"pdf_field":""}],"filled_by":"Policy Holder / Claimant"},{"title":"Hospitalization Details","fields":[{"help":"Include Pin Code and State/Union Territory","type":"text","label":"Name & Full Address of the Hospital/Nursing Home / Clinic","options":[],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the attending Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification and medical registration number","type":"text","label":"Qualification & Registration No.","options":[],"required":true,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Telephone No.","options":[],"required":false,"pdf_field":""},{"help":"Describe the illness or injury","type":"text","label":"Nature of Disease/ailment for which admitted","options":[],"required":true,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date when Disease/ailment was first diagnosed/suspected/contacted","options":[],"required":true,"pdf_field":""},{"help":"Describe injury and date it occurred","type":"text","label":"In case of injury; Nature of Injury & Date on which injury sustained","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is a surgical procedure suggested as part of the treatment by the Doctor consulted?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of the suggested surgery","type":"text","label":"If so, please give details","options":[],"required":false,"pdf_field":""}],"filled_by":"Policy Holder / Claimant"},{"title":"Declaration and Signature","fields":[{"help":"Sign and date the form","type":"signature","label":"Signature of the Policy Holder (Principal Insured) / Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"Policy Holder / Claimant"}],"deadlines":["This form should be submitted prior to hospital admission unless admitted in emergency","Hospital Claim Form along with certified/attested Hospital Records & Medical Certificate should be submitted within 15 days of discharge from the hospital","TPA requires a minimum of 7 working days to process the claim after receiving all required information"],"applies_to":"Health Insurance Policies (HCB & MSB Claims)","attachments":["Bill, Receipt and discharge certificate / card from the Hospital","Cash Memos from the Hospital / Chemist(s), supported by a proper prescription","Receipt and pathological test reports from a Pathologist supported by the prescription from the attending Medical Practitioner / Surgeon for such Pathological tests","Surgeon's certificate stating nature of operation performed and Surgeon's bill and receipt","Attending Doctor's / Consultant's / Specialist's / Anesthetist’s bill and receipt and certificate regarding diagnosis","FIR and related documents in respect of an accidental bodily injury claim (Medico Legal cases)","Copies of doctor’s prescription for the x-ray/scan; the X Ray/scan Bill and the X-Ray/Scan report"],"declarations":["The policyholder warrants the truth of all particulars and understands that false statements or concealment will forfeit claim rights","The policyholder consents to the insurer and TPA seeking medical information from any hospital or medical practitioner who attended the insured","The policyholder authorizes hospital authorities and medical practitioners to share medical information with the TPA and insurer"],"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/lic/2307-claim-intimation-form"}