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SURGICAL CASH BENEFIT CL AIM FORM (SCBCF)
"Ñ|[W¡[A¡;Îà >Kƒ Îå[¤‹à ƒà[¤ ó¡³¢ (&Î[Î[¤[Î&ó¡)
CLAIMS DOCUMENT CHECKLIST (CDCL)
ƒà[¤¹ >[=¹ ëW¡A¡[ºÐ¡ ([Î[l¡[Î&º)
Life Assured Name: \ã¤> [¤³àAõ¡ìt¡¹ >à³
Policy No.: š[º[Î >}.
Please submit this form along with the requirements mentioned below at the nearest branch or address mention ed overleaf for faster
processing of claim.
ƒà[¤¹ ‰ç¡t¡ šø[yû¡ÚàA¡¹ìo¹ \>¸ ">åNøÒ A¡ì¹ [>³¥[º[Jt¡ "à¤Å¸A¡t¡àP¡[º ÎÒ &Òü ó¡³¢[i¡ [>A¡i¡t¡³ ÅàJàÚ "=¤à šõˡ๠[šáì> l¡ü[À[Jt¡ [k¡A¡à>àÚ \³à [ƒ>ú
Please note that all documents needs to be self attested.
">åNøÒ A¡ì¹ ³ì> ¹àJì¤> ë™ ÎA¡º >[= Ѭ-šøt¡¸[Út¡ Ò*Úà šøìÚà\>ú
Hospital Admission due to illness/surgery
S.No.
SCB Claim Requirements
Yes/No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Claim Form duly filled, signed by claimant and duly attested by an authorized person
as mentioned in claim form
Authorization form duly filled and signed
Photocopy of policy schedule
Daily records of treatment during hospitalization
Discharge summary from the hospital stating the proper diagnosis and date & time
of admission and discharge
All laboratory and pathology tests conducted such as blood reports
All investigative tests such as X-Ray, scans, MRI etc.
Relevant questionnaire duly filled (as per the format)
Declaration by the attending physician on the insured’s current state of health
In case of surgery: surgical notes
Final hospital bill including details of room charges (ICU/Normal) and OT charges as
well
Copy of cancelled cheque (Mandatory) with NEFT Mandate Form
Government approved identification proof
Copy of Claimant’s current address proof
In addition to the above documents if
need to be submitted.
1.
2.
3.
Hospital Admission is due to accident following additional documents
Copy of First Information Report (FIR)
Police Final Report
Newspaper cutting
Claim/SCBCF/Ver1.0/1stApr2011
"ÎåÑ‚t¡à/"ìÑ|àšW¡àì¹¹ \>¸ ÒàΚàt¡àìº ®¡[t¡¢
S.No.
&Î[Î[¤ ƒà[¤¹ šøìÚà\>ãÚt¡à
1.
ƒà[¤¹ ó¡³¢ ™=à™= ®¡àì¤ šè¹o A¡¹à, ƒà[¤ƒàì¹¹ ‡à¹à ѬàÛ¡[¹t¡ &¤} ƒà[¤¹ ó¡ì³¢ l¡ü[À[Jt¡ ">åì³à[ƒt¡ ¤¸[v¡û¡¹ ‡à¹à
™=à™= ®¡àì¤ šøt¡¸[Út¡
2.
">åì³àƒ> ó¡³¢ ™=à™= ®¡àì¤ šè¹o A¡¹à &¤} ѬàÛ¡[¹t¡
š[º[Î t¡ó¡[Î캹 ó¡ìi¡àA¡[š
ÒàΚàt¡àìº ®¡[t¡¢ =àA¡à A¡àºã> [W¡[A¡;Î๠íƒ[>A¡ ë¹A¡l¢¡
ÒàΚàt¡àº ë=ìA¡ šøƒv¡ [l¡ÎW¡à\¢ Îà³à[¹ ™àìt¡ Î[k¡A¡ ì¹àK [>o¢Ú &¤} ®¡[t¡¢ * [l¡ÎW¡àì\¢¹ t¡à[¹J * Î³Ú [¤¤õt¡
"àìá
Ò¸òà/>à
3.
4.
5.
6.
γÑz δšà[ƒt¡ º¸à¤ì¹i¡[¹ &¤} š¸à=º[\ š¹ãÛ¡à 뙳> ¹ìv¡û¡¹ [¹ìšài¡¢
ÎA¡º ">åÎÞê¡à> ³èºA¡ š¹ãÛ¡à 뙳> &G-ë¹, ÑHþ¸à>, &³"à¹"àÒü Òüt¡¸à[ƒ¡ú
7.
™=à™= ®¡àì¤ šè¹o A¡¹à šøàÎ[UA¡ šøťऺã (ó¡¹³¸ài¡ ">å™àÚã)
8.
9.
10.
[¤³àAõ¡t¡ ¤¸[v¡û¡¹ ѬàìÑ‚¸¹ ¤t¡¢³à> "¤Ñ‚à δšìA¢¡ š[¹W¡™¢àA¡à¹ã [W¡[A¡;ÎìA¡¹ ìQàÈoà
11.
12.
13.
&>Òü&ó¡[i¡ ³¸àì“¡i¡ ó¡³¢ ÎÒ¡ ¤à[t¡º A¡¹à ëW¡ìA¡¹ A¡[š (¤à‹¸t¡à³èºA¡)
"ìÑ|àšW¡àì¹¹ ëÛ¡ìy: Îà[\¢A¡àº ì>ài¡
Qì¹¹ ³èº¸ ("àÒü[ÎÒül¡ü/Îà‹à¹o) &¤} *[i¡-¹ ³è캸¹ [¤¤¹o ÎÒ ÒàΚàt¡à캹 "[”z³ [¤º
ιA¡à¹ ">åì³à[ƒt¡ š[¹W¡ìÚ¹ šø³àošy
ƒà[¤ƒàì¹¹ ¤t¡¢³à> [k¡A¡à>๠šø³àošìy¹ A¡[š
l¡üšì¹àv¡û¡ >[=šy áàØl¡à* ™[ƒ ƒåQ¢i¡>๠A¡à¹ìo ÒàΚàt¡àìº ®¡[t¡¢ A¡¹à ÒìÚ =àìA¡ t¡àÒìº [>³¥[º[Jt¡ "[t¡[¹v¡û¡ >[=šyP¡[º* \³à [ƒìt¡ Òì¤ú
1.
2.
3.
šø=³ ÎèW¡>à [¹ìšàìi¡¢¹ (&ó¡"àÒü"à¹) A¡[š
šå[ºìŹ "[”z³ [¹ìšài¡¢
Î}¤àƒšìy¹ A¡à[i¡}
Claim/SCBCF/Ver1.0/1stApr2011
SURGICAL CASH BENEFIT CLAIM FORM (SCBCF)
"Ñ|[W¡[A¡;Îà >Kƒ Îå[¤‹à ƒà[¤ ó¡³¢ (&Î[Î[¤[Î&ó¡)
1.Policy No. š[º[Î >}.:
Section I Details of the Life Insured
[¤®¡àK I \ã¤> [¤³àAõ¡ìt¡¹ [¤¤¹o
2.Name of Life Insured: \ã¤> [¤³àAõ¡ìt¡¹ >à³:
First Name šø=³ >à³
Middle Name ³‹¸ >à³
3. Current Residen al Address : ¤t¡¢³à> ¤Î¤àìι [k¡A¡à>à:
(Current Address should) match with Address proof provided
Surname šƒ[¤
Mobile no.:
ì³à¤àÒüº >}.:
(¤t¡¢³à> [k¡A¡à>à šøƒv¡ [k¡A¡à>๠šø³àošìy¹ ÎìU ÎU[t¡šèo¢ Ò*Úà šøìÚà\>)
Phone No. with STD Code:
&Î[i¡[l¡ ìA¡àl¡ ÎÒ ìó¡à> >}:
E‐mail ID:
Pin Code:
Òü-볺 "àÒü[l¡ :
[š> ìA¡àl¡ :
¤¸à}A¡ "¸àA¡àl¡üë@i¡¹ [¤¤¹o: &¹ ÎìU &>Òü&ó¡[i¡ ³¸àì“¡i¡ ó¡³¢ Î}™åv¡û¡ A¡¹à "àìá
4. Bank Account Details: Please find enclosed NEFT Mandate Form
(Please attach a copy of cancelled cheque and passbook copy along with this form)
(&Òü ó¡ì³¢¹ ÎìU ">åNøÒ A¡ì¹ &A¡[i¡ ¤à[t¡º A¡¹à ëW¡ìA¡¹ A¡[š &¤} šàΤÒü-&¹ A¡[š Î}™åv¡û¡ A¡¹ç¡>)
5. Date of Birth: \@µ t¡à[¹J:
6.Employment Details: Name of the Employer’s /Business Name A¡ì³¢ [>™å[v¡û¡¹ [¤¤¹o: [>ìÚàKA¡t¡¢à¹ >à³/¤¸¤Î๠>à³
Address :
[k¡A¡à>à :
Mobile or Phone no. :
Exact nature of Job/ Business:
ì³à¤àÒüº "=¤à ìó¡à> >}.
A¡à\/¤¸¤Î๠™=à=¢ šøAõ¡[t¡
7.
Reason for th e claim: Accident / Sickness / Pregnancy related complica ons. (Please ck the relevant reason.)
Reason for the claim: Accident / Sickness / Pregnancy related complica ons. (Please ck the relevant reason.)
ƒà[¤¹ A¡à¹o: ƒåQ¢i¡>à / "ÎåÑ‚t¡à / K®¢¡à¤Ñ‚à Î}yû¡à”z \[i¡ºt¡àú (">åNøÒ A¡ì¹ l¡üš™åv¡û¡ A¡à¹ìo [i¡A¡ [W¡Òû¡ [ƒ>ú)
ƒåQ¢i¡>à
Accident
Reason
Date & Time of Accident:
ƒåQ¢i¡>๠t¡à[¹J &¤} γÚ
Place of Accident:
ƒåQ¢i¡>๠тà>
How did the accident happen (Please provide full descrip on)?ƒåQ¢i¡>à [A¡®¡àì¤ Qìi¡[Ạ(">åNøÒ A¡ì¹ δšèo¢ [¤¤¹o šøƒà> A¡¹ç¡>)?
Claim/SCBC
F/Ver1.0/1stApr2011
Was the accident reported to the police or to your employer? (Please Tick) Yes / No
ƒåQ¢i¡>à δšìA¢¡ šå[ºÅ "=¤à "àš>๠[>ìÚàKA¡t¡¢àìA¡ [A¡ Îè[W¡t¡ A¡¹à ÒìÚ[áº? (">åNøÒ A¡ì¹ [i¡A¡ [W¡Òû¡ [ƒ>) Ò¸òà/>à
If yes, please give details of the police sta on to which the ma er was reporte
d and a ach copies of statements/ FIR taken by the
police or your employer.
™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ ë™ šå[ºÅ ëСÅì> Qi¡>à[i¡ \à>àì>à ÒìÚ[ẠëÎ[i¡¹ [¤¤¹o [ƒ> &¤} šå[ºÅ "=¤à "àš>๠[>ìÚàKA¡t¡¢à ‡à¹à KõÒãt¡ ¤Úà>&ó¡"àÒü"à¹-&¹ A¡[š Î}™åv¡û¡ A¡¹ç¡>ú
Were any other persons involved in the accident o
r responsible for the accident?(Please Tick) Yes /No
&Òü ƒåQ¢i¡>๠ÎìU ">¸ ìA¡à> ¤¸[v¡û¡ [A¡ \[Øl¡t¡ [áìº> "=¤à &¹ \>¸ ƒàÚã [áìº>? (">åNøÒ A¡ì¹ [i¡A¡ [W¡Òû¡ [ƒ>) Ò¸òà/>à
If yes, please give the name, address and contact numbersof the other persons involved or responsible.
™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ ">¸ ë™ ¤¸[v¡û¡ \[Øl¡t¡ [áìº> "=¤à ƒàÚã [áìº> t¡à¹ >à³, [k¡A¡à>à &¤} ì™àKàì™àìK¹ >´¬¹ šøƒà> A¡¹ç¡>ú
Please provide the names, addresses and contact details of any witnesses who saw the accident occurred.
&Òü ƒåQ¢i¡>à Qi¡ìt¡ ëƒìJìá> &³> ìA¡à> ÎàÛ¡ã =àA¡ìº ">åNøÒ A¡ì¹ t¡à샹 >à³, [k¡A¡à>à &¤} ì™àKàì™àìK¹ [¤¤¹o šøƒà> A¡¹ç¡>ú
What part of the body was injured and what was the nature of injury?
Źãì¹¹ ìA¡à> "}ìÅ "àQàt¡ ëºìK[Ạ&¤} "àQàìt¡¹ ‹¹o [A¡ [áº?
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Surgery
Reason
"ìÑ|àšW¡à¹
What is the surgery which you underwent? "àš>๠ëA¡à> "ìÑ|àšW¡à¹ A¡¹à ÒìÚìá?
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Date on which the first symptoms occurred?
šø=³ l¡üšÎK¢ ëƒJà ëƒ*Ú๠t¡à[¹J [A¡ [áº?
Briefly describe the symptoms from which you sufferedand which resulted in this surgery
"àš[> ë™ l¡üšÎK¢P¡[ºìt¡ ®å¡K[áìº> &¤} ™à¹ \>¸ "àš>๠"ìÑ|àšW¡à¹ A¡¹à ÒìÚ[Ạt¡à¹ Î}ìÛ¡ìš [¤¤¹o [ƒ>ú
How long did you have these symptoms before you first consulted a doctor?
[W¡[A;ÎìA¡¹ ÎìU šø=³ ¤à¹ š¹à³Å¢ A¡¹à¹ A¡t¡[ƒ> "àìK ë=ìA¡ "àš>๠&Òü l¡üšÎK¢P¡[º [áº?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
When was the diagnosis of thesurgery related to sickness made? A¡J> &Òü "ÎåÑ‚t¡à δ¬[Þê¡t¡ "ìÑ|àšW¡àì¹¹ \>¸ ì¹àK [>o¢Ú A¡¹à ÒÚ?
______________________________________________________________________________________________________________
Claim/SCBCF/Ver1.0/1stApr2011
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Pregnancy Related Complica ons eason
K®¢¡à¤Ñ‚à Î}yû¡à”z \[i¡ºt¡à
Date on which the first symptoms of the pregnancy related complica ons occurred
K®¢¡à¤Ñ‚à Î}yû¡à”z \[i¡ºt¡à¹ šø=³ l¡üšÎK¢ ëƒJà ëƒ*Ú๠t¡à[¹J
In which pregnancy week are you now? ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
"àš[> &J> K®¢¡à¤Ñ‚๠ìA¡à> Îœ¡àìÒ "àìá>?
ÒàΚàt¡àìº ®¡[t¡¢ Ò*Úà &¤} [W¡[A¡;Îà
Hospitaliza
for the
on and Treatment
claim:
Date on which medical treatment was started
[W¡[A¡;Îà šøoàºã Ç¡¹ç¡ Ò*Ú๠t¡à[¹J
What treatment was prescribed? ìA¡à> [W¡[A¡;Î๠š¹à³Å¢ ëƒ*Úà ÒìÚ[áº?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Prior to the current period of hospitaliza on, have you ever been treated in the past for this sickness or accident or any related medical
condi ons? Yes/No
¤t¡¢³àì> ÒàΚàt¡àìº ®¡[t¡¢ Ò*Ú๠"àìK "t¡ãìt¡ [A¡ &Òü "ÎåÑ‚t¡à "=¤à ƒåQ¢i¡>à "=¤à &Òü ‹¹ì>¹ ìA¡à> "ÎåÑ‚t¡à¹ \>¸ "àš>๠[W¡[A¡;Îà A¡¹à ÒìÚ[áº? Ò¸òà/>à
If Yes, please provide details below & enclose consulta on notes, discharge summary,hospital reports available with you.
Name of Hospitalwhere Life Insured was recently hospitalized‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ >ãìW¡ t¡à¹ [¤¤¹o šøƒà> A¡¹ç¡> &¤} [W¡[A¡;ÎìA¡¹ ÎìU š¹à³ìÅ¢¹ ì>ài¡ γèÒ, [l¡ÎW¡à\¢ Îà³à[¹, &¤} ÒàΚàt¡à캹 ë™ Î¤ [¹ìšài¡¢ "àš>๠A¡àìá "àìá ëÎP¡[º Î}™åv¡û¡
A¡¹ç¡>ú
\ã¤> [¤³àAõ¡t¡ δß[t¡ ë™ ÒàΚàt¡àìº ®¡[t¡¢ [áìº> t¡à¹ >à³ ____________________________________________________
What was the name of the doctor who referred you to hospital?
___________________________________
ë™ [W¡[A¡;ÎA¡ "àš>àìA¡ ÒàΚàt¡àìº ™à*Ú๠Îåšà[¹Å A¡ì¹[áìº> t¡à¹ >à³ [A¡?
When did the hospitaliza on startand end? (Provide date and mings)
ÒàΚàt¡àìº ®¡[t¡¢ =àA¡à A¡J> Ç¡¹ç¡ &¤} ëÅÈ ÒìÚ[áº? (Î³Ú &¤} t¡à[¹J l¡üìÀJ A¡¹ç¡>)
ICU/CCU
General/ normal ward
Îà‹à¹o/>³¢àº *Úàl¢¡
-----------------------------------------
Was surgery performed for this condi on? Yes /No
&Òü "ÎåÑ‚t¡à¹ \>¸ [A¡ "ìÑ|àšW¡à¹ A¡¹à ÒìÚ[áº?Ò¸òà/>à
"àÒü[ÎÒül¡ü/[Î[ÎÒül¡ü
-----------------------------------------
If ‘Yes’ please provide details with hospital records.
™[ƒ Ò¸òà ÒÚ t¡àÒìº ÒàΚàt¡à캹 ë¹A¡l¢¡ ÎÒ [¤¤¹o šøƒà> A¡¹ç¡>ú
Is further surgery required? Yes/ No
"à¹* ìA¡à> "ìÑ|àšW¡àì¹¹ šøìÚà\> "àìá [A¡? Ò¸òà/>à
If yes, when is this planned?‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
™[ƒ Ò¸òà ÒÚ t¡àÒìº ëÎ[i¡ A¡J> A¡¹à¹ š[¹A¡¿>à "àìá?
Details of surgery planned ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
š[¹A¡[¿t¡ "ìÑ|àšW¡àì¹¹ [¤¤¹o
Was any home leave taken during the period of hospitaliza on? Yes / No
ë™ Î³ÚA¡à캹 \>¸ ÒàΚàt¡àìº ®¡[t¡¢ [áìº> t¡à¹ ³ì‹¸ [A¡ ¤à[Øl¡ ™à*Ú๠\>¸ ìA¡à> áå[i¡ [>ìÚ[áìº>? Ò¸òà/>à
If Yes, on which dates, Were you referred to any other clinic or hospital. If so, please provide the name of the clinic or hospital, dates
of admission and discharge? ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Describe treatment, medica on and therapy undertaken since hospital discharge? ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
™[ƒ Ò¸òà ÒÚ t¡àÒìº ìA¡à> t¡à[¹ìJ, "àš>àìA¡ [A¡ ">¸ ìA¡à> [Aá[>A¡ "=¤à ÒàΚàt¡àìº ™à*Ú๠Îåšà[¹Å A¡¹à ÒìÚ[áºú ™[ƒ ÒìÚ =àìA¡ t¡àÒìº ">åNøÒ A¡ì¹ ëÎÒü [Aá[>A¡ ¤à ÒàΚàt¡à캹 >à³, ®¡[t¡¢ *
[l¡ÎW¡à\¢ Ò*Ú๠t¡à[¹J l¡üìÀJ A¡¹ç¡>?_________________________________________________________________________ÒàΚàt¡àº ë=ìA¡
[l¡ÎW¡à\¢ Ò*Ú๠šì¹ ë™ [W¡[A¡;Îà, *Èå‹šy &¤} ë=¹à[š A¡¹à ÒìÚìá t¡à¹ [¤¤¹o [ƒ>?_________________________________________
____________________________________________________________________________________________
Doctor Informa on
Who was the a ending physician when you were in hospital? ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Please tell us the names of other doctors/ hospitals/ clinics or other medical professionals (e.g. physiotherapists) who a ended you
for this illness and dates of consulta ons? -----------------------------------------------------------------[W¡[A¡;ÎìA¡¹ t¡=¸
"àš[> ™J> ÒàΚàt¡àìº [áìº> t¡J> š[¹W¡™¢àA¡à¹ã [W¡[A¡;ÎA¡ ëA¡ [áìº>?_______________________________________________
“>åNøÒ A¡ì¹ ">¸à>¸ [W¡[A¡;ÎA¡ /ÒàΚàt¡àº/ [Aá[>A¡ ¤à [W¡[A¡;Îà [¤ìÅÈ`¡ (왳> [ó¡[\*ì=¹à[šÐ¡) ™à¹à &Òü "ÎåÑ‚t¡à¹ ƒ¹ç¡> "àš>๠š[¹W¡™¢à A¡ì¹ìá> t¡à샹 >à³ &¤} š¹à³Å¢ A¡¹à¹ t¡à[¹J
"à³à샹 \à>à>? ________________________________________________________________________
Details of Other Insurance Policies on the life of Life Insured lilnt
\ã¤> [¤³àAõ¡ìt¡¹ ">¸à>¸ [¤³à š[º[ι [¤¤¹o
Policy No.
Sum Assured
Name of Insurance
Company/Employer Name
Date of Commencement
Type of Plan
š[º[Î >}.:
"àÅ«à[Ît¡ "=¢¹à[Å
[¤³à ìA¡à´šà[>¹ >à³/[>ìÚàKA¡t¡¢à¹ >à³
Ç¡¹ç¡ Ò*Ú๠t¡à[¹J
š[¹A¡¿>๠‹¹o
Have you previously received reimbursement for this accident, illness, or pregnancy from any other company? Yes / No. If Yes, what is
the name and address of the company?
Declara on and authorisa on
1. I/ we hereby declare that the answers given by me in this form are in all respects truthful and correct. No material informa on has been withheld. The company is authorised to obtain any
informa on in connec on with this claim from any source and I/ We hereby authorise the obtaining of such informa on. A photocopy of this authorisa on shall be as valid as the original.
2. I/ We hereby declare and agree that any personal informa on co llected or held by Aviva Life Insurance (whether contained in this claim form or otherwise obtained) may be held, or
disclosed by the Company to persons or organisa ons associated with the Company or to selecte d third par es including reinsurance and claims inves ga on companies or industry
associa ons to meet any legisla ve requirement.
3. I/ We Authorise that my/our personal informa on may be provided to Aviva Life Insurance by any medical prac oner, hospital and clinic, employer, ins tu ons, or any other person or
persons including any and all informa on about my/our health, medical history, hospitalisa on, advice, diagnosis,treatment, disease or ailment. I/ We also consent to a personal medical
inves ga on as part of my/our claim.
4. As well, I/ We understand we have the right to obtain access to and to request correc on of any personal informa on heldby the Company concerning me/ us. (If you wish to make such a
correc on, please refer to our Customer Service Centres).
Date:
Signature of Life Insured…………………………………..
"àš>àìA¡ [A¡ &¹ "àìK &Òü ƒåQ¢i¡>à, "ÎåÑ‚t¡à, ¤à K®¢¡à¤Ñ‚๠\>¸ ">¸ ìA¡à> ìA¡à´šà[>¹ ë=ìA¡ ¤¸Ú A¡¹à "=¢ š[¹ìÅà‹ A¡¹à ÒìÚìá?Ò¸òà/>àú ™[ƒ Ò¸òà ÒÚ t¡àÒìº ëÎÒü ìA¡à´šà[>¹ >à³ &¤} [k¡A¡à>à [A¡?
ëQàÈoà &¤} ">ìå³àƒ>
1. "à[³/"à³¹à &t¡‡à¹à ìQàÈoà A¡¹[á ë™ &Òü ó¡ì³¢ "à[³ ë™ ÎA¡º t¡=¸ šøƒà> A¡ì¹[á ëÎP¡[º Î¤ Ît¡¸ &¤} Î[k¡A¡ú ìA¡à> P¡¹ç¡â«šèo¢ t¡=¸ ìKàš> A¡¹à ÒÚ[>ú ìA¡à´šà[> ë™ ìA¡à> l¡ü;Î ë=ìA¡ &Òü ƒà[¤ Î}yû¡à”z ë™ ìA¡à> t¡=¸ Î}NøÒ A¡¹à¹ \>¸ ">åì³à[ƒt¡ &¤} "à[³/"à³¹à &t¡‡à¹à &Òü ‹¹ì>¹
t¡=¸ Î}NøìÒ¹ ">å³[t¡ šøƒà> A¡¹[áú &Òü ">åì³àƒì>¹ ó¡ìi¡àA¡[š "àÎ캹 >¸àÚ í¤‹ ¹ê¡ìš Ko¸ A¡¹à Òì¤ú
2. "à[³/"à³¹à &t¡‡à¹à ìQàÈoà A¡¹[á &¤} δ¶[t¡ šøƒà> A¡¹[á ë™ ë™Î¤ ¤¸[v¡û¡Kt¡ t¡=¸ "[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X Î}NøÒ A¡ì¹ìá "=¤à t¡à¹ A¡àìá l¡üšº®¡¸ (&Òü "à줃>šìy¹ ³à‹¸ì³ "=¤à ">¸ ìA¡à> l¡üšàìÚ Î}NøÒ A¡¹à¹ ³à‹¸ì³) ëÎP¡[º ìA¡à´šà[> ‹à¹o "=¤à "àÒü[> šøìÚà\>ãÚt¡à šàº>
A¡¹à¹ \>¸ ëA¡à´šà[>¹ ÎìU ™åv¡û¡ ëA¡à> ¤¸[v¡û¡ "=¤à šø[t¡Ë¡àì>¹ A¡àìá "=¤à šå>[¤¢³à &¤} ƒà[¤ t¡ƒ”zA¡à¹ã ëA¡à´šà[> ÎÒ [>¤à¢[W¡t¡ tõ¡t¡ãÚ šÛ¡ "=¤à [Å¿ Î}ìQ¹ A¡àìá šøA¡àÅ A¡¹ìt¡ šà칡ú
3. "à[³/"à³¹à ">å³[t¡ šøƒà> A¡¹[á ë™ ìA¡à> [W¡[A¡;ÎA¡, ÒàΚàt¡àº &¤} [Aá[>A¡, [>ìÚàKA¡t¡¢à, šø[t¡Ë¡à>, "=¤à ">¸ ìA¡à> ¤¸[v¡û¡ ¤à ¤¸[v¡û¡ ÎA¡º "à³à¹/"à³à샹 ѬàÑ‚¸, [W¡[A¡;Î๠Òü[t¡ÒàÎ, ÒàΚàt¡àìº ®¡[t¡¢ =àA¡à, š¹à³Å¢, ì¹àK [>o¢Ú, [W¡[A¡;Îà, ì¹àK "=¤à "ÎåÑ‚t¡à δš[A¢¡t¡ "à³à¹/"à³à샹
¤¸[v¡û¡Kt¡ t¡=¸ "[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹XìA¡ šøƒà> A¡¹ìt¡ šàì¹ú "à[³/"à³¹à "à³à¹/"à³à샹 ƒà[¤¹ "U ¹ê¡ìš &A¡[i¡ ¤¸[v¡û¡Kt¡ [W¡[A¡;Îà t¡ƒì”z¹ \ì>¸* δ¶[t¡ šøƒà> A¡¹[áú
&áàØl¡à*, "à[³/"à³¹à "¤[Òt¡ "à[á ë™ ìA¡à´šà[>¹ A¡àìá =àA¡à "à³à¹/"à³à샹 δš[A¢¡t¡ ™à¤t¡ãÚ ¤¸[v¡û¡Kt¡ t¡=¸ šà*Ú๠&¤} ëÎP¡[º Î}ìÅà‹ì>¹ \>¸ ">åì¹à‹ \à>àì>๠"[‹A¡à¹ "à³à샹 "àìáú ("àš[> ™[ƒ &³> ìA¡à> Î}ìÅà‹> A¡¹ìt¡ W¡à> t¡àÒìº ">åNøÒ A¡ì¹ "à³à샹 NøàÒA¡ š[¹ìȤà
ëA¡ì@ƒø ì™àKàì™àK A¡¹ç¡>)ú
t¡à[¹J
\ã¤> [¤³àAõ¡ìt¡¹ ѬàÛ¡¹
…………………………
AUTHORISATION
">åì³àƒ>
(To be fille d & signed by the Life Assured)
(\ã¤> [¤³àAõ¡ìt¡¹ ‡à¹à šè¹o A¡¹à &¤} ѬàÛ¡[¹t¡ Ò*Úà šøìÚà\>)
Life Insurance Policy No.(s)
\ã¤> [¤³à š[º[Î >}.(γèÒ)
____________________________________
I, Mr. / Mrs / Ms. ______________________________________
(name of the Life Assured), hereby give my consent to M/s Aviva
Life Insurance Company In dia Limited, and / or its representa ve to obtain all employment / medical / hospital records / police
records / other records (including photocopies) / informa on pertaining to my treatment / occupa on which I might have
acquired whether befor e or a er the policy was issued by the Company as well as details from other Life Insurance Companies
regarding any exis ng policies which I may have sourced before or a er the ini a on of this contract.
"à[³, Åøã/Åøã³[t¡ /A塳à¹ã __________________________ (\ã¤> [¤³àAõ¡ìt¡¹ >à³) &t¡‡à¹à "[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[>
Òü[“¡Úà [º[³ìi¡l¡ &¤}/"=¤à &¹ šø[t¡[>[‹ìA¡ ™à¤t¡ãÚ A¡³¢ [>ìÚàK/ [W¡[A¡;Îà/ ÒàΚàt¡à캹 ë¹A¡l¢¡/šå[ºÅ ë¹A¡l¢¡ /">¸à>¸ ë¹A¡l¢¡ (ó¡ìi¡àA¡[š ÎÒ)
/"à³à¹ [W¡[A¡;Îà Î}yû¡à”z/\ã[¤A¡à ™à "à[³ ìA¡à´šà[> š[º[Î šøƒà> A¡¹à¹ "àìK ¤à šì¹ NøÒo A¡ì¹[á ëÎÒü Î}yû¡à”z t¡=¸ &¤} ëÎÒü ÎìU &Òü Wå¡[v¡û¡ Ç¡¹ç¡
Ò*Ú๠"àëK "=¤à šì¹ ì>*Úà "à³à¹ ™[ƒ ëA¡à> [¤ƒ¸³à> š[º[Î ë=ìA¡ =àìA¡ t¡àÒìº ëÎÒü δšìA¢¡ ">¸ \ã¤> [¤³à ëA¡à´šà[> ë=ìA¡ t¡=¸ šøàœ¡ A¡¹à¹
">å³[t¡ [ƒ[Zá¡ú
Date: t¡à[¹J
Yours faithfully
ইিত ভবদীয়
Place: Ñ‚à>
(Signature of Claimant)
(ƒà[¤ƒàì¹¹ ѬàÛ¡¹)
Contact details of the claimant: ƒà[¤ƒàì¹¹ ÎìU ë™àKàì™àìK¹ [¤¤¹o:
Address: [k¡A¡à>à :
________________________
________________________
________________________
________________________
________________________
Pin: [š> ìA¡àl¡ :
___________________
Landline: STD Code _______ No. ______________
&Î[i¡[l¡ ìA¡àl¡ ÎÒ ìó¡à> >}: :________ ü_______________
Mobile No.: ì³à¤àÒüº >}.
Email id: Òü-볺 "àÒü[l¡ :
__________________
_
___________________________
Claim/SCBCF/Ver1.0/1stApr2011
NEFT Mandate Form: Direct Transfer of Claim amount to your bank
&>Òü&ó¡[i¡ ³¸àì“¡i¡ ó¡³¢ : ƒà[¤ A¡¹à "=¢¹à[ŠιàÎ[¹ "àš>๠¤¸à}A¡ "¸àA¡àl¡üì@i¡ Ñ‚à>à”z¹
Mandatory: Copy of cancelled cheque bearing the below mentioned account number along with this form .
¤à‹¸t¡à³èºA¡ : &Òü ó¡ì³¢¹ ÎìU [>ì³¥ l¡ü[À[Jt¡ "¸àA¡àl¡ü@i¡ >´¬¹ šøƒÅ¢> A¡ì¹ &³> ¤à[t¡º A¡¹à ëW¡ìA¡¹ A¡[š¡ú
To, šø[t¡,
AVIVA life Insurance Company India Limited, "[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡,
Sub: E-Payments vide NEFT [¤ÈÚ: &>Òü&ó¡[i¡-¹ ³à‹¸ì³ Òü-ëšì³@i¡
I/We request and authorize you to effect E-payment vide NEFT mode to my/our Bank account as per the details given below:
"à[³/"à³¹à [>ì³¥ šøƒv¡ [¤¤¹o ">åÎàì¹ "à³à¹/"à³à샹 ¤¸à}A¡ "¸àA¡àl¡üì@i ¡&>Òü&ó¡[i¡-¹ ³à‹¸ì³ Òü-ëšì³@i¡¡ A¡¹à¹ \>¸ "àš>àìA¡ ">åì¹à‹ \à>à[Zá &¤} ">å³[t¡ šøƒà> A¡¹[á:
Full name of the Claimant: ƒà[¤ƒàì¹¹ δšèo¢ >à³:
First Name šø=³ >à³
Middle Name ³‹¸ >à³
Surname šƒ[¤
Full name of the Bank Account Holder as appearing in the Account:
First Name šø=³ >à³
¤¸à}A¡ "¸àA¡àl¡ü@i¡ ‹à¹ìA¡¹ δšèo¢ >ೠ뙳> "¸àA¡àl¡üë@i¡ ëƒ*Úà "àìá:
Surname šƒ[¤
Middle Name ³‹¸ >à³
Bank Account No.: ¤¸à}A¡ "¸àA¡àl¡ü@i¡¡ >}
Bank Name: ¤¸à}ìA¡¹ >à³:
Bank Address ( Including State, City, Pin Code): ¤¸à}ìA¡¹ [k¡A¡à>à (¹à\¸, ÅÒ¹, [š> ìA¡àl¡ ÎÒ) :
Bank Branch contact persons’ names and Tel e nos with STD Code:
¤¸à}ìA¡¹ ÅàJàÚ ë™ ¤¸[v¡û¡ìƒ¹ ÎìU ì™àKàì™àK A¡¹à Òì¤ t¡à샹 >à³ &¤} &Î[i¡[l¡ ìA¡àl¡ ÎÒ ëi¡[ºìó¡à> >´¬¹ :
Account Type: "¸àA¡àl¡üì@i¡¹ ‹¹o:
Saving Account
Îe¡Ú "¸àA¡àl¡ü@i¡
Current Account
A¡àì¹@i¡ "¸àA¡àl¡ü@i¡
Bank Branch IFSC Code No. ( Mandatory for NEFT):
¤¸à}ìA¡¹ ÅàJ๠"àÒü&ó¡&Î[Î ìA¡àl¡ >}. (&>Òü&ó¡[i¡-¹ \>¸ ¤à‹¸t¡à³èºA¡) :
Bank Branch MICR Code: ¤¸à}ìA¡¹ ÅàJ๠&³"àÒü[Î"๠ìA¡àl¡ :
I/We confirm that information provided above is correct and any consequences due to any mistake in above will be borne by me.
"à[³/"à³¹à [>[ÆW¡t¡ A¡¹[á ë™ l¡üšì¹ šøƒv¡ ÎA¡º t¡=¸ Î[k¡A¡ &¤} l¡üšì¹¹ t¡ì=¸ yç¡[i¡¹ š[¹oàì³¹ ƒà[Úâ« "à[³ ¤Ò> A¡¹ì¤àú
Thanking You, ‹>¸¤àƒàì”z,
Name & Signature of the Claimant:
ƒà[¤ƒàì¹¹ >à³ * ѬàÛ¡¹
Bank Verification: ¤¸à}A¡ šø[t¡šàƒ>:
We confirm that we are enabled for receiving for NEFT credits and we further confirm that the account number of the……………………………….
and the signature of the authorised signatory and the IFSC and MICR codes of our branch mentioned above are correct.
"à³¹à [>[ÆW¡t¡ A¡¹[á ë™ "à³¹à &>Òü&ó¡[i¡ ëyû¡[l¡i¡ NøÒo A¡¹ìt¡ ÎÛ¡³ &¤} "à³¹à "à¹* [>[ÆW¡t¡ A¡¹[á ë™ ............................................... &¹ "¸àA¡àl¡ü@i¡¡ >´¬¹ &¤} ">åì³à[ƒt¡ ѬàÛ¡¹A¡à¹ã¹ ѬàÛ¡¹ &¤}
l¡üšì¹ l¡ü[À[Jt¡ "à³à샹 ÅàJ๠"àÒü&ó¡&Î[Î &¤} &³"àÒü[Î"๠ìA¡àl¡ Î[k¡A¡ú
Bank verification Stamp with branch address and Signature of the Banker
ÅàJ๠[k¡A¡à>à &¤} ¤¸à}A¡àì¹¹ ѬàÛ¡¹ ÎÒ ¤¸à}ìA¡¹ šø[t¡šàƒ> С¸à´š
Name of the Signing authority ѬàÛ¡¹A¡à¹ã A¡tõ¡¢šìÛ¡¹ >à³
Claim/SCBCF/Ver1.0/1stApr2011
ACKNOWLEDGEMENT SLIP
šøà[œ¡Ñ¬ãA¡à¹ šy
Policy No.:
š[º[Î >}.:
Name of Claimant: ƒà[¤ƒàì¹¹ >à³:
Interaction ID: Òü@i¡à¹¸àA¡Å> "àÒü[l¡ :
………………………………………………………………………………..
………………………………………………………………………………..
Documents Submitted: Please Tick \³à ëƒ*Úà >[=šy: ">åNøÒ A¡ì¹ [i¡A¡ [W¡Òû¡ [ƒ>
SCB Claim Form and Authorisation Form Signed by the Claimant
ƒà[¤ƒà¹ ‡à¹à ѬàÛ¡[¹t¡ &ÒüW¡[Î[¤ ƒà[¤ ó¡³¢ &¤} ">åì³àƒ> ó¡³¢
Photocopy of policy schedule
š[º[Î t¡ó¡[Î캹 A¡[š
Daily records of treatment during hospitalization
ÒàΚàt¡àìº ®¡[t¡¢ =àA¡à A¡àºã> [W¡[A¡;Î๠íƒ[>A¡ ë¹A¡l¢¡
Discharge summary from the hospital stating the proper diagnosis and date & time of admission and discharge
ÒàΚàt¡àº ë=ìA¡ šøƒv¡ [l¡ÎW¡à\¢ Îà³à[¹ ™àìt¡ Î[k¡A¡ ì¹àK [>o¢Ú &¤} ®¡[t¡¢ * [l¡ÎW¡àì\¢¹ t¡à[¹J * Î³Ú [¤¤õt¡ "àìá
All laboratory and pathology tests conducted such as blood re ports
γÑz δšà[ƒt¡ º¸à¤ì¹i¡[¹ &¤} š¸à=º[\ š¹ãÛ¡à 뙳> ¹ìv¡û¡¹ [¹ìšài¡¢
All investigative tests such as X -Ray, scans, MRI etc.
ÎA¡º ">åÎÞê¡à> ³èºA¡ š¹ãÛ¡à 뙳> &G-ë¹, ÑHþ¸à>, &³"à¹"àÒü Òüt¡¸à[ƒ¡ú
Relevant questionnaire duly filled (as per the format)
™=à™= ®¡àì¤ šè¹o A¡¹à šøàÎ[UA¡ šøťऺã (ó¡¹³¸ài¡ ">å™àÚã)
Declaration by the attending physician on the insured’s current state of health
[¤³àAõ¡t¡ ¤¸[v¡û¡¹ ѬàìÑ‚¸¹ ¤t¡¢³à> "¤Ñ‚à δšìA¢¡ š[¹W¡™¢àA¡à¹ã [W¡[A¡;ÎìA¡¹ ìQàÈoà
In case of surgery: surgical notes
"ìÑ|àšW¡àì¹¹ ëÛ¡ìy: Îà[\¢A¡àº ì>ài¡
Final hospital bill including details of room charges (ICU/Normal) and OT charges as well
Qì¹¹ ³èº¸ ("àÒü[ÎÒül¡ü/Îà‹à¹o) &¤} *[i¡-¹ ³è캸¹ [¤¤¹o ÎÒ ÒàΚàt¡à캹 "[”z³ [¤º
Copy of cancelled cheque Mandatory with NEFT Mandate Form
&>Òü&ó¡[i¡ ³¸àì“¡i¡ ó¡³¢ ÎÒ ¤à[t¡º A¡¹à ëW¡ìA¡¹ A¡[š (¤à‹¸t¡à³èºA¡)
Government approved identification proof
ιA¡à¹ ">åì³à[ƒt¡ š[¹W¡ìÚ¹ šø³àošy
Copy of Claimant’s current address proof
ƒà[¤ƒàì¹¹ ¤t¡¢³à> [k¡A¡à>๠šø³àošìy¹ A¡[š
Copy of First Information Report (FIR)
šø=³ ÎèW¡>à [¹ìšàìi¡¢¹ (&ó¡"àÒü"à¹) A¡[š
Police Final Report
šå[ºìŹ "[”z³ [¹ìšài¡¢
Newspaper Cutting
Î}¤àƒšìy¹ A¡à[i¡}
Processed by (Name &
Signature):
šøfêìÎÎ
(>à³
ѬàÛ¡¹)
LÈêkA¡ì¹ìá>
–ÇLlZ LlÈ
bÈg&¤}
Ç gèvÈ
(eÇi: J
cÂMa):
BRANCH STAMP WITH
RECEIPT DATE:
šøà[œ¡¹ t¡à[¹J ÎÒ ÅàJ๠С¸à´š:
Claim Contact Points
Mailing Address:
For any urgent queries contact:
For any queries please write to:
Aviva Life Insurance Company India Ltd.
rd
3 Floor. Aviva Towers, Sector ‐43,
Opposite DLF Golf Course,
Gurgaon‐122003
Customer service Helpline Number
1800‐180‐22‐66 (Toll Free)
[email protected]
0124‐2709046
ƒà[¤¹ \>¸ ë™àKàì™àK Ñ‚º
šy šàk¡àì>๠[k¡A¡à>à:
ìA¡à> \¹ç¡[¹ šøÅ¥ =àA¡ìº ë™àKàì™àK A¡¹ç¡> :
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l
3Ú t¡º "[®¡®¡à i¡à*Úà¹, ëÎC¡¹- 43,
NøàÒA¡ š[¹ìȤà ÎÒàÚt¡à >´¬¹
1800‐180‐22‐66 (ëi¡àº [óø¡)
ìA¡à> [\`¡àθ =àA¡ìº šy šàk¡à> &Òü [k¡A¡à>àÚ:
[email protected]
[l¡&º&ó¡ Kºó¡ ëA¡àë΢¹ [¤š¹ãìt¡, P¡¹Kòà*-122003
0124‐2709046
A Joint Venture between Dabur Invest Corp & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph- V, Sector 43, Gurgaon-122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
l¡à¤¹ Òü>쮡С A¡š¢ &¤} "[®¡®¡à Òü@i¡à¹>¸àÅ>ຠëÒà[Á¡}Î [º[³ìi¡ìl¡¹ &A¡[i¡ ì™ï= l¡ü샸àK
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡
ëÒl "[ó¡Î: "[®¡®¡à i¡à*Úà¹, ëÎC¡¹ ì¹àl¡, [l¡&º&ó¡ Kºó¡ ìA¡àì΢¹ [¤š¹ãìt¡, [l¡&º&ó¡ ëó¡\ V, ëÎC¡¹ 43, P¡¹Kòà*-122003ú Ò[¹Úà>à Òü[“¡Úàú
[>¤[Þê¡t¡ A¡à™¢àºÚ: 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢, [>l¡ü [ƒ[À-110001ú Òü[“¡Úà
Tel/ ëi¡[ºìó¡à>:+91 (o) 124 270 9000 Fax/ ó¡¸àG: +91 (0) 124 257 1210.
www.avivaindia.com Email/ Òü쳺 :[email protected]
Claim/SCBCF/Ver1.0/1stApr2011