Sanghavi Insurance

Insured Details

Name of the Insured *

Insured Email Address *

You will receive claim form on this email address

Contact Number *

Insured Date of Birth

City *

State *

Pincode *

Address *

Same As Insured Address

Patient Name *

Patient Relationship with Insured *

Date of Birth

Date of Admission *

Time of Admission

Date of Discharge *

Time of Discharge

City *

State *

Pincode *

Address *

Claim Intimation No *

Name of Insurance Company *

Mediclaim Policy Number *

Policy End Date *

Name of Hospital *

City *

State *

Pincode

Hospital Address *

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