Hospitalization & Critical Illness Claim

• Claim Forms (Download this form in other Language)
  For Hospitalization:
  1. Part I: Accident / Hospitalisation Claim Form – (Claimant's Statement)
  2. Part II: Accident / Hospitalisation Claim Form – (attending Physician's report)
  For Critical Illness:
  1. Part I: Application Form for Critical Illness ( Life Assured's Statement)
  2. Part II: Confidential Medical Report (to be filled by attending physician)
• Copies of Hospital Bills for the confinement & Copies of all related clinical Reports pertaining to the claim event
• Attested True Copy of Indoor Case Papers of the hospital
• Discharge summary of present and past hospitalizations
• Photo Identity of Life Assured with age and address proof  (List of acceptable ID and Address proofs of claimant)
• Bank Details of the claimant – Cancelled cheque (with printed name and account number) / bank passbook and NEFT Form
• Medical Examination Certificate (First Consultation Notes)
• All related clinical Reports pertaining to the claim event
  1. Laboratory test reports
  2. X-Ray / CT Scan / MRI Reports & Plates
  3. Ultrasonography Report
  4. Histopathology Report
  5. Clinical / Hospital Reports
  6. Angiography Reports & Plates
  7. Others (please specify)
  8. Certificate of Diagnosis

All follow-up Consultation Notes in relation to the hospitalized condition.

If hospitalisation is due to accidental causes (submit in addition to the above)

• Reason for delay in intimation.
• All police reports / First Information Report & Final Investigation Report
• Proof of accident - Panchnama / Inquest report
• Newspaper cutting / Photographs of the accident - if available.

Please Note:

• Please submit copies of the following documents certified / attested by the issuing authority. ( Original Seen Verified (OSV) by Branch Personnel will also be accepted) -
  1. All Police papers – Panchnama, Inquest, First Information Report and Final Investigation Report
  2. Medical Records (Admission Notes, Discharge/Death Summary, Indoor Case Papers, Test Reports etc)
• Copies of the other documents to be submitted by self attestation of the claimant
• In case the claim warrants any additional requirement, TALIC reserves the right to call for the same.
• Notification of claim & submission of the claim requirements does not mean admission of the claim liability by the Company.
• No agent is authorized to admit any liabilities on behalf of the Company, nor to alter this list of documents or any claims requirements called for by the Company.