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Domiciary Form - TMP

This document is a statement of claim form from National Insurance Company Ltd. for domiciliary (at-home) treatment of an employee of Lufthansa German Airlines. The form collects information about the employee, patient, treating physician, diagnosis, treatment duration and costs, and bills/reports. The employee declares that the claims have not been made to any other insurance source.

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39 views1 page

Domiciary Form - TMP

This document is a statement of claim form from National Insurance Company Ltd. for domiciliary (at-home) treatment of an employee of Lufthansa German Airlines. The form collects information about the employee, patient, treating physician, diagnosis, treatment duration and costs, and bills/reports. The employee declares that the claims have not been made to any other insurance source.

Uploaded by

సాయి కశ్యప్
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NATIONAL INSURANCE COMPANY LTD.

(A SUBSIDIARY OF GENERAL INSURANCE CORPORATION OF INDIA)


(REGD. OFFICE: 3, MIDDLETON STREET, CALCUTTA 700071)
D.O. - II, 3RD Floor, Deendayal Upadhay Bhawan
7-E, Jhandewalan Extn., New Delhi- 110065
Ph.: 352 6260, 352 8386, 751 8660 Fax: 752 7982

Statement of Claim for Domiciliary Treatment


Name of Employer

Lufthansa German Airlines

1.

Employee's Name

2.

Employee Number

3.

Name of Patient

4.

Department/ Location

5.

Relationship with Employee

6.

Age

7.

Name of Physician

8.

Qualification & Regn. No.

9.

Address

10.

Covered w.e.f

11.

Diagnosis

12. Duration of treatment

..
From

To

DOCTORS'FEE

Rs.

(State number of visits)


Please attach the bills,
reports, prescriptions, etc

Cost of Medicines

Rs.

X/Ray/ E.C.G./ Pathological Tests

Rs.

Other Tests

Rs.

Total Rs.

Date

DENTAL TREATMENT

Rs.

EYE (Non Surgery)

Rs.

Total Enclosures

Rs.

I hereby declare that the foregoing statements are true in every respect and made without any reservation & no benefits
have been claimed/ received from any other source.

Date

Signature

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