OPD Claim Form
Please fill out all details
Full Name (Poora Naam)
Designation (Ohda)
Who is this claim for? (Yeh claim kis k lien hai)
Self (Apna)
Mother (Ammi)
Father (Abu)
Spouse (Biwi)
Children (Bachy)
What type of Claim is? (Claim ki kea kism hai)
Consultation (Mushawarat)
Medicine (Dawa)
Test (Jaanch)
Hospitalization (Hospital me daakhla)
Other (Degar)
Symptoms (Ilamat)
Enter Symptoms
Consultation Amount (Mushawarat ki raqam)
Consultation Amount in Rs.
Test Amount (Jaanch ki raqam)
Test Amount in Rs.
Medicines Amount (Dawa ki raqam)
Test Amount in Rs.
Upload Claim Documents & Bills. (Claim k dastavaiz or bills yahn attach karen)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Click here to read Health Insurance Policy for further clarification.
Last update 23rd Dec 2023
Should be Empty: