THE ORIENTAL INSURANCE COMPANY LIMITED
Regd. Office : 'ORIENTAL HOUSE' P.B. No.7037, A 25/27, Asaf Ali Road, New Delhi - 110 002

CLAIM FORM FOR OVERSEAS MEDICLAIM POLICY (E&S)
(To be submitted to below mentioned address for lodging claim)
CORIS INTERNATIONAL
RUE AUBER, 75009, PARIS, FRANCE
Name of Person Claiming : Mr. / Mrs.
Home Address in India :
Occupation: Day : __________ Time : ____________ Tel No. : _________________
DETAILS OF POLICY C.O. CODE OFFICE CODE PLAN CATEGORY SERIAL NO
Date – Policy Issued:
Date – Trip Commenced :
No. of Days :
Scheduled Date of Return:
Geographical Limits Worldwide Excl. Worldwide Incl.
USA / CANADA USA / CANADA
NAME AND AGE OF EACH PERSON INCLUDED IN THE CLAIM
Date of Birth
Mr. / Mrs. / Miss. Initials Surname ____ / ____ / ______
DD MM YY
DATE OF CLAIM OCCURANCE: TRIP DESTINATION:
PLEASE COMPLETE APPROPRIATE SECTION OF CLAIM FORM AND READ CAREFULLY THE INSTRUCTIONS
RELATING TO SUPPORTING DOCUMENTS REQUIRED. WHEN COMPLETED PLEASE SIGN DECLARATION :
I Declare that to the best of my knowledge all particulars contained in this form are true. I also authorize Coris to obtain my medical records or information necessary to process the claim.
Signed: Date: Place:
Policy Number
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MEDICAL AND EMERGENCY EXPENSES / HOSPITAL
BENEFIT / PERSONAL ACCIDENT
(INCLUDING ADDITIONAL TRAVEL, ACCOMODATION EXPENSE)
I ) DOCUMENTS REQUIRED :
The following documents must be enclosed with your completed claim form :
· ORIGINAL CERTIFICATE OF INSURANCE TOGETHER WITH ANY COPIES OF AIRLINE TICKET
· ORIGINAL BILLS OR RECEIPTS FOR FULL AMOUNT OF CLAIM ( PHOTOCOPIES NOT ACCEPTABLE )
· CONFIRMATION BY HOSPITAL OF DATES OF HOSPITALISATION ( FOR CLAIMS FOR HOSPITAL BENEFITS )
· DEATH CERTIFICATE ( FOR DEATH CLAIM)
· DISABLEMENT CERTIFICATE AND POLICE REPORT ( FOR CLAIM BY ACCIDENT)
· THE MEDICAL CERTIFICATE DOES NOT NEED TO BE COMPLETED FOR MINOR ACCIDENTS OR ILLNESS
· PHYSICIAN’S REPORT ( ORIGINAL ATTACHED TO THE POLICY IF APPILCABLE )
These documents must be supplied with the completed claim form at the Claimant’s expense. Failure to do so will delay the
processing of your claim and could result in it being declined.
II ) TO BE COMPLETED BY THE CLAIMANT OR THE CLAIMANT’S LEGAL REPRESENTATIVE :
1. Name of Sick or Injured Person :
2. Nature of Injury / Illness :
3. Date of Injury / Illness :
4. Place of Injury / Illness :
5. Circumstances of Injury :
6. If claim was due to hospitalization or confinement, was the Emergency Assistance Department contacted YES / NO. If no,
please advise why, on an additional information sheet.
7. Dates of Hospitalization : From - To –
8. Details of Claim :
9. Details of any third parties involved in accidental injury or death of insured person.
10. Details of Private Health Insurance
a) Name of Insurer :
b) Address of Insurer :
c) Policy Number :
d) Telephone Number :
Details of Claimed Expenses, Providers Name, Prescription
Charges, etc.
Amount Charged in
Local Currency
IMPORTANT
Has Bill Been
Paid By You*
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
TOTAL AMOUNT
*Delete where
Applicable
- 3 -
II) TO BE COMPLETED BY THE CLAIMANT OR THE CLAIMANT’S LEGAL PERSONAL
REPRESENTATIVE.
1) Time, Date and Place of Loss :
2) Full Circumstances of Loss :
3) Name and Position of any other person in authority to whom the matter was reported.
ADDITIONAL INFORMATION YOU MAY WISH TO GIVE IN SUPPORT
OF YOUR CLAIM UNDER ANY SECTION OF THE POLICY
SPECIAL SETTLEMENTS – U. S. A
When a medical incident has occurred in the USA with total bills not exceeding $500/ - in all, the Insured may also post the policy schedule and this fully completed claim form together with the original medical invoices to Coris International, Coris International, 200, S. E. First Street, Suite 602, MIAMI, FL 33131., E-mail : corisusa [at] aol [dot] com , Assistance Center : Tel : 1 305 372 0071 / 1 305 358 91 00 , Fax 1 305 371 6108 , Management, Administration and Claims, Tel. : 1 305 371 2961, Fax.: 1 305 371 5693. On receipt, Coris will immediately arrange payment either to the Insured or to the Medical Provider. If the claim cannot be paid for any reason (such as incomplete claim form or lack of documentation) or if the claim is for a greater amount than US$ 500/- then Coris will deal with it under the normal settlement procedures in the France.
Toll Free Nos. in U.S.A.
1) 1-877-536-7264 (Within U.S.A)
2) 305 – 358 –2102 (Within the State of Miami only)
In case of filing the claim on return to India, the above-referred documents may be posted to M/s. Heritage Health Services Pvt. Ltd., Unit 28, Ground Floor, T V Industrial Estate (Behind Glaxo), Hind Cycle Road, Worli, Mumbai – 400 025.
The payment of a claim in this manner does not prejudice the Insurer’s right to decline further payments if the claim is subsequently found to be invalid.
TO BE SIGNED BY THE INSURED.
I wish my claim, which does not exceed US$ 500/- in all, to be dealt with under the above special arrangement.
SIGNATURE :
Once a claim becomes payable under the terms and conditions of the policy and any costs have been met by you or any person on your behalf please indicate below to whom you would like the cheque be made payable to and their full address:
Payees Name :
Address :
Once a claim becomes payable under the terms and conditions of the policy and any costs
have been met by you or any person on your behalf please indicate below to whom you
would like the cheque be made payable to and their full address :
Payees Name :
Address :