@if($data['data']['claim_intimation_type'] != "Death Claim" || $data['data']['claim_type_name'] != "Life Insurance Death Claim")

Step 1

Choose Claim Lodged Type*

Regular Claim

Post-Pre Exp. Claim

Deduction Claim

Rejected Claim

Rejected Re-Open

Going To Court

Court Settlement Entry

Choose Claim Lodged Type*

Own Vehicle Damage

TP Vehicle Damage

Own Vehicle Total Loss

TP Vehicle Total Loss

Own Person Injury

TP Person Injury

Pre

Claim Intimation Details

Intimation date

Policy Number

Policy Holder Name

Insurance Company Name

Admission Date

Driver / TP Person Name

Garage Name

Patient Name

Hospital Name

Nominee Name

Nominee Contact No.

Vehicle Name

Vehicle Number

Reason Of Admission

Branch Name

Policy Sum Assured

Model

RTO

Bank Name

Policy Address

Policy Type

Client Type

TP Due Date

Segment

Life Insurance Plan Name

Broker Name

Incident Date

Sub Agent Name

Agency Name

Risk From Date

Risk To Date

Incident Address

Short Detail Of Incident

Reason Of Incident

Claim Settlement Details

Policy No.

Claim Intimation Date

Claim Type

Admission Date

Hospital Name

Patient Name

Policy Holder Name

Policy Due Date

Company Name

TPA Name

Claim Settlement Details

Settlement Date

Admission Date

Discharge Date

Patient Name

Policy No.

Policy Due Date

Total Claim Lodged Amt.

Claim Type

Total Claim Settled Amt.

Total Deducted Amt

Deduction Claim Count

Reason For Deduction

Rejection Date

Refference Details

Claim Settlement Details

Transaction Date

Document Number*

Claim No.

Rejected Reopen Count

Claim Amount

Name Of Court

City

Reason For Going To Court

Date Of Filing Case

Court Order Date

Decision

Approved Amount

Short Detail Of Court Decision

Remarks

@endif

Step 2

Claim Type

Claim Lodged Entry

Transaction Date*

Document Number*

Claim No.

@if($data['data']['claim_intimation_type'] != "Death Claim")

Submited Surveyer Report ?*

Yes

Submited Fire Station Docs. ?*

Yes

Submited Police Station Docs. ?*

Yes

Submited Expense Annu-A ?*

Yes

@endif

Date Of Discharged*

Vehicle Driving By

Total Claim Amount*

File Received Date*

File Submited Date*

File Online Upload Date

Claim Submited At

Direct Company

TPA Company

Broker

Claim Submited To*

This value is required.

Claim Submited By

Agent

Office Staff

Policy Holder

Note: [2] For E-Mail

{{--

Garage Name

--}}

Pre Expences Claim

Post Expences Claim

Pre Expences Amount

Post Expences Amount

Total Amount

Claim Count

Bills-Docs Enclosed Nos

Reason For Pre-Post Expences Claim

NOTE :- Required Bills, Prescriptions,Reports, Forms etc are enclosed herewith

@if($data['can_edit'] == 0)

Sr. No.*

Deduction Re-Claimed Amount

Reason For Deduction Re-Claim

Row

@endif

@if($data['can_edit'] == 0)

Sr. No.*

Claimed Amount

Reason For Claim Rejection

Row

@endif

@if($data['can_edit'] == 0)

Sr. No.*

Claimed Amount

Reason For Claim Rejection

Reason For Re-Open The Claim

Document Attached(JPG, PNG, JPEG or PDF)

Row

@endif

Rejection Re-open Count

Remarks

Request For Re-Open The Claim :-

We had attached all required and supported document for Re-Open this Claim. You are requested to Re-Open this claim and approve it.

Name Of Court

City

Reason For Going To Court

Date Of Filing Case

Rejection Re-open Count

Remarks

Intimation Transaction Date

Intimation Date

Intimation Document Number

Policy Holder Name

Insurance Company Name

Branch Name

Nominee Name

Nominee Contact Number

Death Of Death

Death Person Name

Death Claim Type

Reason Of Death

Illness Name

Short Detail Of Death

Destination Of Death

Hospital Name & Address

If Accident-Police Station Name

Intimation Date

Intimation Document Number

Accident Date

Intimated Through

Online

Call Center

Others

Intimation To…

Direct Company

TPA Comapny

Intimated By

Agent

Office Staff

Policy Holder

Relation

Remarks

Sum Assured

Term Rider Sum Assured

Accident Sum Assured

Double Accident Sum Assured

Below Documents Are Enclosed Here With For Above Claim:

[1] All Required Claim Forms of The Compny was Fully Filluped , Signed and Stamped are enclosed here with

[2] All Required Docs. Of Death Person are Enclosed Here with

[3] All Required Docs. Of Nominee Person are Enclosed Here with

[4] All Docs are enclosed here with which are regarding of Incident

[5] All Docs are enclosed here with which are regarding of Hospitals

[6] All Docs are enclosed here with which are regarding of Police /Fire and Other Govt.Depts

[7] All Original Policy Documents are enclosed here with as per Policy list

[8] Claimed Policy List is enclosed Here with

@if($data['data']['claim_intimation_type'] != "Other Claim" && $data['data']['claim_intimation_type'] != "Death Claim")

Step 3

Expenses Bill Annexure - A

@if($data['can_edit'] == 0 || $data['bill_count'] == 0)

Claim Expense Type*

This value is required.

Sr. No.*

Bill Date

Bill No.

Bill Amount*

Bill Issued By Name

Remarks For Bill

Row

Sr. No.*

Bill Date

Bill Issued By Name

Bill No.

Bill Amount*

Remarks For Bill

Row

@endif

[ A ] Hospitalized Bills Total -->

[ B ] Pharmacy - Medicine Bills Total -->

[ C ] Lab-X'Ray - Investigation Bill -->

[ D ] Other Hospitalized Exp. Bills -->

@endif

Step 4

@if($data['can_edit'] == 0)

Claim Document Type*

This value is required.

Claim Document Name*

This value is required.

Upload Document(JPG, PNG, JPEG or PDF)*

Nos

@endif

{{$data['title']}}

Step 1

Step 2

Below Documents Are Enclosed Here With For Above Claim:

Step 3

Step 4