{"id":372,"title":"Wellness Reward Points Accumulation (OPD) Form","purpose":"service","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/wellness-rewards-points-accumulation-form.pdf","sha256":"6721be3cae6a4f05dc4d6deef46ccf62961a64a3591487fc5fd34d7fa2fe41fe","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by policyholders or insured persons to accumulate wellness points by submitting bills and details of health and fitness activities.","notes":["Fill in CAPITAL letters only.","Separate claim form to be filled for every insured person for accumulation of points.","As per IRDA, all claims shall be settled in electronic mode only; provide correct bank account details.","PRA refers to Preventive Risk Assessment.","Males above age 45 and females above age 45 are eligible for certain tests.","This form issuance is not an admission of liability."],"title":"Wellness Reward Points Accumulation (OPD) Form","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016"},"purpose":"service","sections":[{"title":"Details of Bills and Activities","fields":[{"help":"","type":"text","label":"Bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Hospital/Diagnostic","options":[],"required":null,"pdf_field":""},{"help":"Select applicable activity or bill type","type":"choice","label":"Activity Heads/ Bills (As applicable)","options":["Heart related screening tests (under PRA ) above 45 years","HbA1c/ Complete lipid profile (under PRA ) any age","PAP Smear (under PRA) Females*","Mammogram (under PRA) Females*","Prostate Specific Antigen (PSA) (under PRA) Males**","Any other test as suggested by Our empanelled Medical expert (under PRA)","Gym/ Yoga membership for 1 year","Participation in Professional sporting events like Marathon/ Cyclothon/ Swimathon, etc.","Participation in any other health & fitness activity/ event organized by ICICI Lombard","Quit smoking- based on self declaration","Share your fitness success story","On winning any health quiz organized by ICICI Lombard"],"required":null,"pdf_field":""},{"help":"Enter the bill number","type":"text","label":"Bill No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of the bill","type":"date","label":"Bill Date","options":[],"required":null,"pdf_field":""},{"help":"Check if the bill is attached","type":"checkbox","label":"attached","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of the Insured Person","fields":[{"help":"Enter full name of the insured person","type":"text","label":"Name of Insured:","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to policyholder","type":"text","label":"Relationship with the Policy Holder :","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Present completed age (in years) :","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender :  M         F","options":["M","F"],"required":null,"pdf_field":""},{"help":"Enter full residential address","type":"text","label":"Current Residential address:","options":[],"required":null,"pdf_field":""},{"help":"Enter city","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter landline number if available","type":"phone","label":"Landline No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail:","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Policy Holder Details","fields":[{"help":"Enter full name of policyholder or proposer","type":"text","label":"Name of Policy Holder/Proposer:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Current Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter card number or UHID","type":"text","label":"Card No./UHID:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant/ Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant/proposer"}],"deadlines":[],"applies_to":"","attachments":["Bills/receipts/other supporting/related documents"],"declarations":["The information given in this form is true, correct and complete to the best of my knowledge.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of bills does not constitute admission of claim liability; company may require further information.","I consent to ICICI Lombard seeking medical information from any hospital or medical practitioner who attended the insured.","I have included all bills/receipts for this claim and will not make any supplementary claim.","Expenses claimed have been incurred in respect of the insured."],"dropped_labels":1},"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/icici-lombard-general-insurance/372-wellness-reward-points-accumulation-opd-form"}