Sanghavi Insurance

Name of the Insured ^*

Insured Email Address ^* You will receive claim form on this email address

Contact Number ^*

Insured Date of Birth

Address ^*

City ^*

State ^*

Pincode ^*

Patient Name ^*

Patient Relationship with Insured ^*

Date of Birth

Date of Admission ^*

Time of Admission

Date of Discharge ^*

Time of Discharge

Same As Insured Address

Address ^*

City ^*

State ^*

Pincode ^*

Claim Intimation No ^*

Name of Insurance Company ^*

Mediclaim Policy Number ^*

Policy End Date ^*

Name of Hospital ^*

City ^*

State ^*

Hospital Address ^*

Pincode ^*

TAB KEY HELPS IN ADDING ROWS

No	Bill From	Dated	Amount


Bill Total
Less Cashless Already Paid By
Hospital Cash Benefit / Daily Allowance Amount Per Day
Total Hospital Cash Benefit / Daily AllowanceTotal
Grand Total Claim

Bank Account Number

Bank Name

IFSC Code

Pan Card