THE ORIENTAL INSURANCE COMPANY LIMITED
The Oriental Insurance Company Limited
Regd. Office : Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002

CLAIM FORM FOR PRAVASI BIMA YOJANA-06

Name of Claimant : Mr. / Mrs. ________________________________________
Home address and Telephone No. in India_____________________________________
___________________________________________________________________________
PERSONAL DETAILS OF INSURED PERSON :
Name Mr. / Mrs. _________________________________ Age ________________
Home address and Telephone No. in India_____________________________________
__________________________________________________________________________
Insurance I.D. No/Policy No.. ___________________________________________
Period: From _______________ to_______________________________________
Occupation _________________Country of Employment _____________________
Passport No.___________________Place of Issuance________________________
POLICY SECTION RELATING TO CLAIM Tick Boxes
Section – IA Personal Accident Benefits-
Section – 1B Family Floater Hospitalization Cover
Section – IIA Re-iamb. of Repatriation/Transportation Exp.
Section- IIB Re-iamb of Repatriation/Transportation Exp.
Section– IIC Litigation Expenses
Section – III(A) Hospitalization
Section – II(B) Maternity benefit(Woman Emigrant)
Date of Injury / Illness _____________________________________________________
Nature of Injury / Illness ______________________________________________________
Place of Injury / Illness _______________________________________________________
Details of Expenses Claimed ____________________________________________________
Any other information_________________________________________________________
_________________________________________________________________________
PLEASE COMPLETE APPROPRIATE SECTION OF CLAIM FORM AND READ CAREFULLY
THE INSTRUCTIONS RELATING TO SUPPORTING DOCUMENTS REQUIRED. WHEN
COMPLETED PLEASE SIGN DECLARATION:
THE ORIENTAL INSURANCE COMPANY LIMITED 2
I declare that to the best of my knowledge all particulars contained in this form are true. I also
authorize __________________ Third Party Administrator to obtain medical records or
information necessary to process the claim from Hospital concerned or otherwise.
Name ___________________________ Signature _____________
Date __________________________ Place________________
DOCUMENTS REQUIRED
The following documents must be enclosed with your completed claim form :
1 Original Insurance Certificate / Policy
2. Copy of Insurance I.D. Card
3. Attested copy of Pass Port (All pages)
Applicable for all type
of claims
4 Death Certificate issued by the Competent Authority
5 Post Mortem Report
6 Certificate/Report of the concerned Indian Embassy
Applicable for Accidental Death cases only
7 Police Report
8 Disability Certificate issued by the Competent Medical Authority
alongwith other relevant medical documents
Applicable for Death &
Permanent Disability
claim
9 Air-lines tickets alongwith medical advices for the) accompanying
person, if applicable
10 Grounds for repatriation certified by concerned Indian Mission /
Post.
11 Certificate from the Competent Medical Authorities lodged
Confirming that the insured person contracted the only Major
Ailment(s) during the period of employment Contract, if applicable
12 Documentary proof confirming that service contract of the insured
person is terminated on account of the Insured perils only
Applicable for claims
under Sections II
13 Certificate by appropriate ministry of that company against the
foreign employer.
Actual expenses certified by Indian Mission / Post.
Legal Expenses
incurred against
employer.
14 a. Original bills, receipts and discharge certificate / card from the
hospital.
b. Medical history of the patient recorded by the Hospital.
c. Original Cash-memo from the hospital (s) / chemist (s)
supported by proper prescription.
d. Original receipt, pathological and other test reports from a
pathologist / radiologist including film etc supported by the
note from attending medical practitioner / surgeon demanding
such tests.
e. Attending consultants / Anaesthetists / Specialist certificates
regarding diagnosis and bills / receipts etc.
f. Surgeon’s original certificate stating diagnosis and nature of
operation performed along with bills / receipts etc.
g. Any other information required by Insurance Company.
All the above documents must be duly attested by the Insured.
The above documents should be duly certified by concerned
Indian Mission / post if in case of emergency treatment is taken by
the Emigrant Insured in the country of employment.
Applicable if treatment
not taken in the
Networking Hospital
The required documents must be supplied with the Claim Form duly completed in all
respects by the Claimant at his/her expense. The claimant shall also provide such further
documents and information as may be sought by the Company from time to time. Failure to
do so will delay the processing of your claim and could result in it being declined.