{"id":905,"title":"National Non-Medical Expenses Add-on 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/Non-Medical%20Expenses%20Add-on%20Claim%20Form.pdf","sha256":"fd4a7acd38fa187d752fbdeb90ac13d08f34e1b341f624babdd9600f8d0c7535","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim reimbursement for non-medical expenses under the National Non-Medical Expenses Add-on policy.","notes":["Submit all original documents and/or certified copies related to the hospitalization.","Fill the form in block letters.","The issue of this form is not to be taken as admission of liability."],"title":"National Non-Medical Expenses Add-on CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Original Bills","fields":[{"help":"","type":"text","label":"Bill Towards","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"No. of bills","options":[],"required":null,"pdf_field":""},{"help":"List serial number of each bill","type":"number","label":"Sl. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the bill number","type":"text","label":"Bill No.","options":[],"required":null,"pdf_field":""},{"help":"Date of the bill","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of the issuer of the bill","type":"text","label":"Issued By","options":[],"required":null,"pdf_field":""},{"help":"Amount in Indian Rupees","type":"amount","label":"Amount (₹)","options":[],"required":null,"pdf_field":""},{"help":"Start date of the claim period","type":"date","label":"Date from","options":[],"required":null,"pdf_field":""},{"help":"End date of the claim period","type":"date","label":"Date to","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Permanent Account Number of the insured","type":"text","label":"a) PAN:","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"b) Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank","type":"text","label":"c) Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Branch of the bank","type":"text","label":"d) Bank Branch","options":[],"required":null,"pdf_field":""},{"help":"Details for cheque or demand draft payment","type":"text","label":"e) Cheque/ DD Payable details:","options":[],"required":null,"pdf_field":""},{"help":"Indian Financial System Code of the bank branch","type":"text","label":"f) IFSC Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"Provide details of the claim","type":"text","label":"a) Details of Claim","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Documents Submitted - Check List","fields":[{"help":"Tick if claim form is signed","type":"checkbox","label":"Claim Form Duly signed","options":["Claim Form Duly signed"],"required":null,"pdf_field":""},{"help":"Tick if diagnosis document is attached","type":"checkbox","label":"Diagnosis","options":["Diagnosis"],"required":null,"pdf_field":""},{"help":"Tick if claim intimation copy is attached","type":"checkbox","label":"Copy of the claim intimation, if any","options":["Copy of the claim intimation, if any"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing the declaration","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of the insured:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"National Non-Medical Expenses Add-on","attachments":["Original bills with itemized break-up","Claim form duly signed","Diagnosis document","Copy of the claim intimation, if any"],"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.","I consent and authorize TPA / insurance company to seek necessary medical information from any hospital or medical practitioner.","I have included all bills and receipts for this claim and will not make any supplementary claim except pre/post-hospitalization claims, if any."],"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/national-insurance/905-national-non-medical-expenses-add-on-claim-form"}