Paramount Health Services & Insurance TPA Pvt. Ltd.

Policy / Insured Information

Insurance Company :		Policy No :		Policy Period. :
Group Name :		PHS ID :		Insured Name :
Patient Name :		Emp. Code :		Relation :
Age :		Gender :
* Email ID :	Enter Email id	* Mobile No. :	Enter 10 Digit Mobile Number	* Location :	Please select Location

Hospitalisation Information

* Claim Type :

* Claim Amount :

Enter Claim Amount

* State :

* City :

* Name of Hospital :

* Other Hospital Name & Address:

* Date of admission :

* Diagnosis / Ailment :

* Treating Doctor :

Enter Dr. Name

I accept all the below terms and conditions.
I hereby confirm that I have gone through the Excluded Hospitals List given by the insurer and I understand that cashless claim cannot be availed at these hospitals.

Terms and conditions * marked fields are mandatory
I hereby authorize Paramount Health Insurance & TPA Services Private Limited / Insurance company / Representative of insurance company to obtain my medical record / Information from Hospital / Nursing Home / Treating medical professionals / Family physician / Diagnostic centre / medical shops necessary to process the claims
1. Non submission of claim document within stipulated time of policy terms will result the claim as “NO CLAIM”.
2. Submit the physical copy of your claim documents to the nearest location.

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Policy / Insured Information

Hospitalisation Information

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