stream 0000120259 00000 n /Type /Catalog /ID [] This form should be completed, signed and dated by both the parent/guardian and the school principal. /Name /F0 CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A TO BE FILLED IN BY THE INSURED The issue of this form is not to be taken as an admission of liability Bajaj Allianz General Insurance Company Limited. No Date of registration Regional/Branch Office Code Broker/Agent Code 1. Free Look Period: If you are not satisfied with the Bajaj Allianz Personal Accident Health Insurance policy, you can cancel the policy within 15 days of receipt of the policy documents, provided there has been no claim. /P 0 0000146092 00000 n CLAIM FORM. 0000130160 00000 n 0000126873 00000 n /ItalicAngle 0 GROUP PERSONAL ACCIDENT INSURANCE. Bajaj Allianz Personal Guard Plan is a Personal Accident Insurance Policy which offers compensation in case of death or bodily injury to the insured person, directly and solely as a result of an accident, by external, visible and violent means and covers medical expenses incurred by a person due to any accident. 500 500 500 500 500 500 278 278 564 564 • Claim is payable subject to the policy being in force on the date of event and fulfilment of all terms and conditions of the policy. 444 480 200 480 541 778 500 778 333 500 The completed form should be returned to Allianz as soon as possible after the accident has occurred. 0000004011 00000 n /Outlines 5 0 R /FontName /TimesNewRoman << Any claim incurred as a result of accident contracted during the break period will not be admissible under the policy. 722 722 722 722 722 722 889 667 611 611 611 611 333 333 333 333 722 722 722 722 /ID [ <129EF8B0D4CF37D337794C3BBC403B1C> Fill and submit this form to the Bajaj Allianz Cliam Office along with all the required documents. << /ImageB PERSONAL ACCIDENT POLICY PROPOSAL FORM 18) Details of the persons to be insured Sr No Name DOB (dd/mm /yy) Age Gender ... Bajaj Allianz Official / Intermediary Name: ... on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement. Customer ID Plot No/Door No. Bajaj Allianz General Insurance Co. Ltd Regd. 0000010165 00000 n %%EOF 0000137230 00000 n endobj 444 1000 500 500 333 1000 556 333 889 778 /E 147538 453 250 333 300 310 500 750 750 750 444 /FontBBox [ -250 -216 1158 1000 ] 11 0 obj 0000137629 00000 n 0000131942 00000 n /Font << /Type /XRef To apply for this plan, you need to be: • Between the age of 18 to 65 years. >> /Info 7 0 R << : +91 20 3030 5858, 1800 22 5858, 1800 102 5858 1. Bajaj Allianz General Insurance Co. Ltd. G.E. This form ... Particulars of accident to be furnished by the Employer. /im1 30 0 R /F4 24 0 R Copy of FIR (filed with the local police authorities) Claim Form (to be filled and signed by insured) Release of Medical Information Form (ROMIF) BAJAJ and AGA (to be filled and signed by insured) to obtain the medical records from facility endobj startxref 0000147386 00000 n /XObject << 0000147462 00000 n 722 333 389 722 611 889 722 722 556 722 Check out the personal accident claim process of bajaj allianz general insurance. 0000146418 00000 n 3. Personal or car accidental injuries are covered under this plan. 0000003329 00000 n 500 500 500 500 ] 0000001869 00000 n 0000139170 00000 n s8W,anb0TCjE[TE6\2WiCoA@gV`/k(Bq*&6^Y.T3oDJRdrr2oqrr2N`qD!&n$!Np- stream 0000139252 00000 n This accidental insurance cover provides cashless facility, easy claim settlement and tax benefits. 0000131668 00000 n When making a claim. Phone No. 17 0 obj • Dependents must be between the age of 5 to 21 years. 0000001933 00000 n 564 444 921 722 667 667 722 611 556 722 << CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A TO BE FILLED IN BY THE INSURED The issue of this form is not to be taken as an admission of liability Bajaj Allianz General Insurance Company Limited. the claim or Our obligation to make payment for it. 0000001328 00000 n /Extensions<< /ADBE<< /BaseVersion/1.7/ExtensionLevel 3>>>> %���� 0000118592 00000 n /FirstChar 32 /H [ 1382 196 ] << /Linearized 1 /Length 304 %%EOF ] 0000145987 00000 n 0000146930 00000 n /F2 20 0 R << Office & Head Office : GE Plaza, Airport Road, Yerwada, Pune - 411 006 SHOPKEEPERS INSURANCE POLICY 1. 0000009818 00000 n 333 980 389 333 722 778 444 722 250 333 x�c```b``MgP```��p� �)@�Bج��������� (f`p ��"�"$n����| �*�HK�@ZH_b= ^�0�����'�v u_� & Head Office: GE Plaza, Airport Road, Yerawada, Pune – 411006 GROUP PERSONAL ACCIDENT POLICY Our agreement to insure your employees/members herein after termed as “Insured Person(s)” named in All you need to do is go online, download the claims form from the official website of Bajaj Health Insurance, fill the form correctly and then finally submit this claim form with the required documents at any branch of Bajaj Allianz Health Insurance Company. /ProcSet 13 0 R Name of Proposer Proposal Form Important : This proposal for insurance wil l be the basis of any subsequent insur ance polic y that we issue to you. >> endobj /Leading 149 endobj Regd. 0000136984 00000 n 564 333 760 500 400 549 300 300 333 576 1. These questions are to be answered whether or not a claim … /Pages 6 0 R Bajaj Allianz is one of the top general insurers in the country with different types of health insurance products in its lineup. 0000145210 00000 n /ImageI ] Regd. 0000003047 00000 n /Filter /FlateDecode /Size 82 Personal Accident . /Type /Catalog 0000117872 00000 n Bajaj Allianz Personal Accident Insurance Policy is a personal accident cover that provides financial support following the death or disability of the insured person. 667 556 611 722 722 944 722 722 611 333 0000006750 00000 n 0000147310 00000 n endobj 0000005344 00000 n 278 333 469 500 333 444 500 444 500 444 >> If you are Bajaj Finserv’s loan customer you can easily get a Personal Accident Insurance. 0000147006 00000 n 500 500 333 389 278 500 500 722 500 500 /BaseFont /TimesNewRoman 5.Statement of how the Accident / Theft occured : D D M M Y Y (2) Declaration 1. Return the completed Accident Report Form to Allianz with any accompanying medical / dental bills or receipts, including the policy number. endobj << 0000118019 00000 n /L 21696 In such an event of withdrawal of this product, 14 0 obj /Subtype /TrueType >> PJDpVd#53X)J,`(m.BE-o\Sj&>*6N&qQJ#u 0000013950 00000 n 0000009543 00000 n Bajaj Allianz Car Insurance Claim The purpose of buying any kind of insurance is incomplete if you are not aware of the company’s claim process. /Length 103 0000008433 00000 n /PageMode /UseNone >> /Text xref >> endobj 0000120341 00000 n [ /PDF /Type /FontDescriptor startxref 0000126911 00000 n /O 12 Bajaj Allianz Personal Accident Health Insurance Plan Key Features and Benefits. 10 0 obj /Widths [ 250 333 408 500 500 833 778 180 333 333 This form may only be used if you have a Bajaj Allianz Health Insurance policy for yourself or your employee, you need to make sure you fill all the required details correctly and then submit the form to the Bajaj Allianz claim office along with the other required documents. 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