{"id":900,"title":"National Critical Illness Policy 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/National%20Critical%20Illness%20Claim%20Form.pdf","sha256":"f08d0e6baaa9c35bdb74e4ab8d820b38257ec5d0d43877b48df78479cd8bce36","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the National Critical Illness Policy and is to be filled by the insured person.","notes":["To be filled in block letters.","Use dd-mm-yy format for dates unless otherwise specified.","Attach original bills and receipts.","The issue of this form is not to be taken as admission of liability."],"title":"National Critical Illness Policy CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number","type":"text","label":"a) Policy no:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder","type":"text","label":"c) Name:","options":[],"required":null,"pdf_field":""},{"help":"Include Street, City and Pin Code","type":"text","label":"d) Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No:","options":[],"required":null,"pdf_field":""},{"help":"Complete e-mail address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID No","type":"text","label":"b) Company/ TPA ID No:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION B - DETAILS OF INSURANCE HISTORY","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"a) Currently covered by any other Mediclaim/ Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"b) Date of commencement of first insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"c) If yes, company name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C - DETAILS OF INSURED PERSON","fields":[{"help":"Surname, First name, Middle name","type":"text","label":"a) Name :","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"b) Gender :","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"d) Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Enter the total sum insured as per the policy","type":"amount","label":"e) Sum insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"i) CB (if any)","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify.","type":"choice","label":"f) Relationship to Primary Insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify.","type":"choice","label":"g) Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Enter the full postal address","type":"text","label":"h) Address (if different from above):","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION D - DETAILS OF CLAIM","fields":[{"help":"Enter name of the covered disease contracted","type":"text","label":"a) Name of the disease contacted","options":[],"required":null,"pdf_field":""},{"help":"Enter date when the covered disease was diagnosed (supported by documents)","type":"date","label":"b) Date of Diagnosis made","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of institution diagnosing the disease","type":"text","label":"c) Name of the Institution giving the Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter present condition of insured","type":"text","label":"d) Present condition of the patient","options":[],"required":null,"pdf_field":""},{"help":"Indicate whether previously covered by another Mediclaim / Health Insurance","type":"yes-no","label":"e) Previously covered by any other Mediclaim/ Health Insurance :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"f) If yes, Company Name :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS OF ENCLOSERS","fields":[{"help":"Attach certificate from the doctor confirming the diagnosis and all relevant supporting documents","type":"text","label":"DETAILS OF ENCLOSERS","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION F - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT","fields":[{"help":"Enter the permanent account number","type":"text","label":"a) PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank account number","type":"text","label":"b) Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank name along with the branch","type":"text","label":"c) Bank Name and Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the beneficiary the cheque/ DD should be made out to","type":"text","label":"d) Cheque/ DD Payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch","type":"text","label":"e) IFSC Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION H - DECLARATION BY THE INSURED","fields":[{"help":"Mention date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place","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":"National Critical Illness Policy claims","attachments":["Certificate from the doctor confirming the Diagnosis","All bills / receipts for the purpose of this claim","Supporting documents with respect to statements under Section D"],"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.","I consent and authorize TPA / insurance company to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made.","I have included all the bills / receipts for the purpose of this claim and will not make any supplementary claim except the pre/post-hospitalization claim, if any."],"dropped_labels":4},"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/900-national-critical-illness-policy-claim-form"}