EMP Code		Full Name*
Policy No*		Card No*
Email		Phone Number
Pancard		Relation*	Select Self Wife Son Doughter father mother
Dependent Name		Dependent Card No.
Claim Type*	Select Hospitalization Domiciliary	Upload Claim File
Hospitalization Name of Hospital Address Name of Patient Age Name of Disease Date of Admission Time Date of Discharge Time Hospitalisation Charges Room & Board/day No of days Cost of Medicine Nursing Attendance Other Expenses Total Surgeon's Fee Name of Surgeon Name of Surgical Operation Performed at Hospital Performed on date Opration Charges Incidental Expenses Total Special Services Anaesthesia Oxygens Blood Transfusion Use of OT charges Surgical Appliance & Eye Glasses Medicine & Injections X-Rey X-Ray doc Pathological Pathological doc E.C.G E.C.G doc Total Consultation Fees of Medical Practioners/Specialists Name of Medical/Practioner/Consultant Dignosis Consultation on date Charges Consultation on date Charges Consultation on date Charges Consultation on date Charges Consultation on date Charges
Domiciliary Name of Physician Address Qualification& Regd No. Name of Patient Age Diagnosis Location Duration of Treatment from Duration of Treatment to Surgeon's Fee Doctor's Fees Cost of Medicines X-Rey X-Ray doc E.C.G E.C.G doc Pathological Test Pathological doc Other Test Other tests doc Total Eye/Dental Treatment Treatment Type Select Eye Dental Dentist/Specialists Fee Cost of Medicines X-Rey X-Ray doc Other Test Other tests doc Total