{"id":914,"title":"Overseas Mediclaim Policy for Employment & Studies 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/OMP%20E%26S%20-%20Claim%20Form.pdf","sha256":"227d63f22a7d34178ca5b4b4a4dae2c2fa790ff3fd60b432848b6e0251c57a20","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to claim benefits under the Overseas Mediclaim Insurance Policy for Employment & Studies.","notes":["All fields are mandatory; do not leave any field blank; write NA if not applicable.","Original bills only; photocopies are not acceptable except where specified.","Use the exact format for dates as dd/mm/yyyy.","Strike off sections not claimed for.","The medical certificate is not required for minor accidents or illness.","For loss of property claims, submit Property Irregularity Report and all relevant correspondence.","For delayed baggage claims, submit property irregularity report and letter from carrier confirming delay details."],"title":"Overseas Mediclaim Policy for Employment & Studies Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"Enter your policy number exactly as on your policy document.","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter the policy start date in dd/mm/yyyy format.","type":"date","label":"Date of policy commencement (dd/mm/yyyy)","options":[],"required":true,"pdf_field":""},{"help":"Enter the date your course started in dd/mm/yyyy format.","type":"date","label":"Date of course commencement (dd/mm/yyyy)","options":[],"required":true,"pdf_field":""},{"help":"Enter the name of your insurance plan.","type":"text","label":"Plan name","options":[],"required":true,"pdf_field":""},{"help":"Enter the full name of the university where you are studying.","type":"text","label":"Name of university","options":[],"required":true,"pdf_field":""},{"help":"Enter the total duration of your course.","type":"text","label":"Duration of course","options":[],"required":true,"pdf_field":""},{"help":"Enter the scheduled date of your return in dd/mm/yyyy format.","type":"date","label":"Scheduled Date of Return","options":[],"required":true,"pdf_field":""},{"help":"Enter the country where you are studying.","type":"text","label":"Country study","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Details of the Insured Person","fields":[{"help":"Enter the full name of the insured person.","type":"text","label":"(a) Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the current age in completed years.","type":"number","label":"(c) Present age in completed years","options":[],"required":true,"pdf_field":""},{"help":"Enter the occupation of the insured person.","type":"text","label":"(d) Occupation","options":[],"required":true,"pdf_field":""},{"help":"Enter the full residential address in India.","type":"text","label":"(e) Residential address in India","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Section of policy under which claim is made","fields":[{"help":"Indicate Yes or No if claim is under Section 1 – Medical.","type":"yes-no","label":"Section 1 – Medical","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate Yes or No for Sub Section A.","type":"yes-no","label":"Sub Section A","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate Yes or No for Sub Section B.","type":"yes-no","label":"Sub Section B","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate Yes or No for Sub Section C.","type":"yes-no","label":"Sub Section C","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate Yes or No for Sub Section D.","type":"yes-no","label":"Sub Section D","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate Yes or No if claim is under Section 2 – Contingency insurance.","type":"yes-no","label":"Section 2 – Contingency insurance","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Claim Occurrence Details","fields":[{"help":"Enter the date when the claim event occurred in dd/mm/yyyy format.","type":"date","label":"Date of claim occurrence (dd/mm/yyyy)","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Bank Details","fields":[{"help":"Enter the name exactly as in your bank account.","type":"text","label":"Name as in bank account in India","options":[],"required":true,"pdf_field":""},{"help":"Enter the name of your bank.","type":"text","label":"Bank name","options":[],"required":true,"pdf_field":""},{"help":"Enter the branch name and full address.","type":"text","label":"Branch name & address","options":[],"required":true,"pdf_field":""},{"help":"Enter your bank account number.","type":"text","label":"Account no.","options":[],"required":true,"pdf_field":""},{"help":"Specify the type of bank account (e.g. Savings, Current).","type":"text","label":"Account type","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC code of your bank branch.","type":"text","label":"IFSC code","options":[],"required":true,"pdf_field":""},{"help":"Enter the MICR code of your bank branch.","type":"text","label":"MICR code","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Section 1 Sub Section A - Medical Claim Details","fields":[{"help":"Enter the name of the person who was sick or injured.","type":"text","label":"Name of Sick or Injured Person","options":[],"required":true,"pdf_field":""},{"help":"Describe the injury or illness.","type":"text","label":"Nature of Injury / Illness","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of injury or illness in dd/mm/yyyy format.","type":"date","label":"Date of Injury / Illness","options":[],"required":true,"pdf_field":""},{"help":"Enter the place where injury or illness occurred.","type":"text","label":"Place of Injury / Illness","options":[],"required":true,"pdf_field":""},{"help":"Explain the circumstances of the injury or name the illness.","type":"text","label":"Circumstances of Injury/ name of illness","options":[],"required":true,"pdf_field":""},{"help":"Indicate if Emergency Assistance Department was contacted and explain if not.","type":"yes-no","label":"If claim was due to hospitalisation or curtailment, was the Emergency Assistance Departmental contacted (YES/NO). If not, please advice why?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Enter the start and end dates of hospitalisation in dd/mm/yyyy format.","type":"date","label":"Dates of Hospitalisation From: To:","options":[],"required":true,"pdf_field":""},{"help":"Provide details of any third parties involved.","type":"text","label":"Details of any third parties involved in accidental injury or death of insured person.","options":[],"required":true,"pdf_field":""},{"help":"Provide details if insured has other health insurance.","type":"text","label":"Details of any other health insurance cover by the insured","options":[],"required":true,"pdf_field":""},{"help":"Name of other insurer if applicable.","type":"text","label":"Name of Insurer","options":[],"required":true,"pdf_field":""},{"help":"Address of other insurer.","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Policy number of other insurance.","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Telephone number of other insurer.","type":"phone","label":"Tel. No.","options":[],"required":true,"pdf_field":""},{"help":"List claimed expenses with provider names, prescription charges, amount charged in local currency, and if bill has been paid by you (YES/NO).","type":"table","label":"Details of Claimed Expense, Providers Name, Prescription Charges, etc.","options":[],"required":true,"pdf_field":""},{"help":"Enter the total claim amount.","type":"amount","label":"Total claim amount","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or claimant's legal personal representative"},{"title":"Section 1 Sub Section B - Medical Evacuation","fields":[{"help":"Indicate if medical evacuation was necessary.","type":"yes-no","label":"Medical evacuation to India was necessary? (Yes/ No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter the date of evacuation in dd/mm/yyyy format if applicable.","type":"date","label":"If yes, date of evacuation","options":[],"required":false,"pdf_field":""},{"help":"Enter name and designation of person who approved evacuation.","type":"text","label":"Name & designation of person approving evacuation","options":[],"required":false,"pdf_field":""},{"help":"Enter name and address of licensed physician who approved evacuation.","type":"text","label":"Name & address of licensed physician approving evacuation","options":[],"required":false,"pdf_field":""},{"help":"Enter name of family member residing with insured if any.","type":"text","label":"Name of family member residing with insured (if any)","options":[],"required":false,"pdf_field":""},{"help":"Enter relation of family member with insured.","type":"text","label":"Relation with insured","options":[],"required":false,"pdf_field":""},{"help":"Enter claim amount for evacuation.","type":"amount","label":"Claim amount","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or claimant's legal personal representative"},{"title":"Section 1 Sub Section C - Death Claims","fields":[{"help":"Enter date of death in dd/mm/yyyy format.","type":"date","label":"Date of death of the insured","options":[],"required":false,"pdf_field":""},{"help":"Enter date of funeral if applicable.","type":"date","label":"Date of funeral, if incurred in the country of posting or education","options":[],"required":false,"pdf_field":""},{"help":"Enter date of approval by claims administrator.","type":"date","label":"Date of approval by claims administrator","options":[],"required":false,"pdf_field":""},{"help":"Enter name and designation of claims administrator.","type":"text","label":"Name & designation of claims administrator","options":[],"required":false,"pdf_field":""},{"help":"Enter claim amount for death claim.","type":"amount","label":"Claim amount","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or claimant's legal personal representative"},{"title":"Section 1 Sub Section D - Medical Evacuation of Relative","fields":[{"help":"Enter date of medical evacuation of insured.","type":"date","label":"Date of medical evacuation of insured","options":[],"required":false,"pdf_field":""},{"help":"Enter name of relative travelling.","type":"text","label":"Name of the relative travelling","options":[],"required":false,"pdf_field":""},{"help":"Enter relation of relative with insured.","type":"text","label":"Relation with insured","options":[],"required":false,"pdf_field":""},{"help":"Enter date of onward travel.","type":"date","label":"Date of onward travel","options":[],"required":false,"pdf_field":""},{"help":"Enter airline and flight number.","type":"text","label":"Airlines & Flight no.","options":[],"required":false,"pdf_field":""},{"help":"Enter name and address of hotel where stayed.","type":"text","label":"Name & address of the hotel where stayed","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days of accommodation.","type":"number","label":"No. of days of accommodation","options":[],"required":false,"pdf_field":""},{"help":"Enter date of return travel.","type":"date","label":"Date of return travel","options":[],"required":false,"pdf_field":""},{"help":"Enter claim amount for relative's evacuation.","type":"amount","label":"Claim amount","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or claimant's legal personal representative"},{"title":"Total claim amount under Section 1","fields":[{"help":"Enter total claim amount under Section 1.","type":"amount","label":"Total claim amount under Section 1","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Section 2 - Contingency Insurance","fields":[{"help":"Provide time, date and place of loss or delay.","type":"text","label":"Time, Date and Place of Loss / Delay","options":[],"required":false,"pdf_field":""},{"help":"Describe full circumstances of loss or delay.","type":"text","label":"Full Circumstances of Loss / Delay","options":[],"required":false,"pdf_field":""},{"help":"Enter number of months completed in course.","type":"number","label":"No. of months completed in course","options":[],"required":false,"pdf_field":""},{"help":"Provide any additional information supporting your claim.","type":"text","label":"Additional information you may wish to give in support of your claim under any section of the policy (Please mention section number)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or claimant's legal personal representative"},{"title":"Declaration","fields":[{"help":"Enter the date of signing in dd/mm/yyyy format.","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter the place of signing.","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form here.","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Overseas Mediclaim Insurance Policy for Employment & Studies","attachments":["Original certificate of insurance","Original bills or receipts for full amount of claim (photocopies not acceptable)","Confirmation by hospital of dates of hospitalisation (for claims for hospital benefits)","Death certificate (for compensation claims of death by accident)","Physician’s report (original attached to the policy if applicable)","Physician’s report suggesting cancer screening/mammography (original)","Approval by claims administrator and licensed physician (for evacuation claims)","Airline tickets of insured and one relative staying with insured (if any)","Police report (if any)","Bills and other documents supporting repatriation or funeral","Recommendation by licensed physician (if applicable)","Airline return ticket of the relative","Bills and other documents supporting travel and stay of the relative","Property Irregularity Report (PIR) for loss of property claims","Receipts or documentation proving value of lost baggage","Correspondence with airline for baggage claims","Letter from carrier confirming reason and duration of delayed baggage","Copy of passport/visa with entry & exit stamps (if any)","Copy of bail (for relevant claims)","Letter from institute stating expenses due for claimed period","Medical records, bills, history, discharge summary, death certificate (if any) regarding hospitalisation"],"declarations":["The statements and particulars given are true and complete to the best of the knowledge of the insured.","The information provided forms the basis of the insurance policy and the policy is effective only after full premium receipt.","The insured will notify in writing any change in occupation or health after proposal submission but before risk acceptance.","Consent is given to the company to seek medical information from doctors, hospitals, and past or present employers for underwriting and claim settlement.","Authorization is given to share proposal and medical records with government and regulatory authorities for underwriting and claims settlement."],"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/914-overseas-mediclaim-policy-for-employment-and-studies-claim-form"}