CORONA KAVACH POLICY,EDELWEISS GENERAL INSURANCE COMPANY LIMITEDCLAIM FORM A

Just follow these simple instructions: 1. This form has to be filled in BLOCK letters by the Insured Person2. This form is not an admission of liability.

a) Name of Hospital where Admitted:

b) Room category occupied: Day Care Single Occupancy Twin Sharing 3 or more beds per room General Ward

c) Expenses related to: Hospitalization due to Covid -19 Confirmed Case or Home care treatment expenses of Covid-19

d) Date the disease was first detected:

e) Date of Admission: Time:

f) Date of Discharge: Time:

g) System of Medicine used for treatment:

D D M M Y Y Y YD D M M Y Y Y Y H H : M M

H H : M MD D M M Y Y Y Y

SECTION D – DETAILS ABOUT THE HOSPITAL / HOME CARE EXPENSES, PLEASE

a) Are you currently covered by any other Mediclaim/ Health Insurance: Yes No

b) Date of start of first Insurance without break:

c) If Yes, Company Name: Policy Number: Sum Insured (`):

d) Have you been hospitalized in the last four years since start of the contract? Yes No

Date: Diagnosis:

e) Were you previously covered by any other Mediclaim / Health Insurance: Yes No

f) If yes, Company Name:

D D M M Y Y Y Y

M M Y Y Y Y

SECTION B – SHARE YOUR PAST/OTHER INSURANCE INFORMATION

SECTION A – SOME DETAILS ABOUT YOU AND YOUR POLICYa) Policy Number: b) Sl. No ./ Certificate No:

c) Company/ TPA ID No.:

d) Name: e) Address:

City: State: Pin Code:

Phone Number: Email ID:

a) Name: b) Gender: Male Female Third Gender

d) Age: years months e) Date of Birth:

f) Relationship with Primarily Insured: Self Spouse Child Father Mother Other (Please Specify)

g) Occupation: Service Self-employed Homemaker Student Retired Other (Please Specify)

h) Address (if different from above):

City: State: Pin Code:

Phone Number: Email ID:

D D M M Y Y Y Y

SECTION C – A BIT ABOUT THE PERSON HOSPITALIZED

Corona Kavach Policy, Edelweiss General Insurance Company Limited I UIN: EDLHLIP21079V012021Page 1 of 3

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Need to claim? We’re here to make it easy!

a) PAN: b) Account Number:

c) Bank Name and Branch:

d) Cheque/DD Payable details: e) IFSC:

SECTION G - THE PRIMARY INSURED’S BANK ACCOUNT DETAILS

DATA ELEMENTSECTION A - DETAILS OF PRIMARY INSUREDa) Policy No.b) SI. No/ Certificate No.

c) Company TPA ID No.

d) Namee) AddressSECTION B - DETAILS OF INSURANCE HISTORYa) Currently covered by any othe Mediclaim/Health Insurance?

b) Date of Start of first insurance without break c) Company Name Policy No. Sum Insuredd) Have you been Hospitalized in the last four years since inception of the contract? Date Diagnosise) Previously Covered by any other Mediclaim/Health Insurance?

f) Company Name

DESCRIPTION

Enter the policy numberEnter the social insurance number or the certificate number of social health insurance schemeEnter the TPA ID No.

Enter the full name of the policyholderEnter the full postal address

Tell us if the insured person is currently covered by another Mediclaim/Health Insurance Enter the date of start of first insuranceEnter the full name of the insurance companyEnter the policy numberEnter the total sum insured as per the policyTell us if you’ve been hospitalised in the last four years

Enter the date of hospitalizationEnter the diagnosis detailsTell us if the insured person was previously covered by another Mediclaim/Health Insurance. Enter the full name of the insurance company

FORMAT

As given by the insurance company As given by the organization

License number as allotted by IRDAI and printed in TPA documentsSurname, First name, Middle nameInclude Street, City and Pin Code

Tick Yes or No

Use dd-mm-yy format

Name of the organization in fullAs allotted by the insurance companyTick Yes or No

Use mm-yy formatOpen TextTick Yes or No

Name of the organization in full

GUIDANCE FOR FILLING CLAIM FORM – PART A (TO BE FILLED BY THE INSURED PERSON)

Sr.No. Bill No. Date Issued by Towards Amount (`)1

2

3

4

5

Hospital Main bill

Pre-Hospitalization Bills: ___ Nos

Post-Hospitalization Bills: ___Nos

Pharmacy Bills

(DD/MM/YYYY)

(DD/MM/YYYY)

(DD/MM/YYYY)

(DD/MM/YYYY)

(DD/MM/YYYY)

SECTION F – DETAILS OF YOUR TREATMENT BILLS

Corona Kavach Policy, Edelweiss General Insurance Company Limited I UIN: EDLHLIP21079V012021Page 2 of 3

a) Details of the treatment expenses claimed(i) Pre-hospitalization Expenses: ` (ii) Hospitalization Expenses: `(iii) Post-hospitalization Expenses: ` (iv) Ambulance Charges: `(v) Pre-hospitalization period: ` (vi) Post-hospitalization period: days (vii) Hospital Daily Cash in case of add on cover ` Total: `

b) The documents we’ll need Signed Claim Form Operation Theatre Notes if applicable Copy of the claim intimation, if any ECG if applicable Hospital Main bill Doctor's request for investigations Hospital Break-up bill Investigation Reports (Including CT/MRI / USG / HPE) Hospital Discharge summary Doctor’s Prescriptions or Treatment Notes Hospital Bill Payment Receipt Others like Nursing Notes or Indoor Case Papers Pharmacy Bill Any other document, please specify

SECTION E – ABOUT YOUR CLAIM

SECTION C - DETAILS OF INSURED PERSON HOSPITALIZEDa) Nameb) Genderc) Aged) Date of Birthe) Relationship to primary Insuredf) Occupationg) Addressh) Phone Noi) E-mail IDSECTION D - DETAILS OF HOSPITALIZATIONa) Name of Hospital where admittedb) Room category occupiedc) Expenses pertaining to d) Date the Disease was first detected e) Date of admission Timef) Date of discharge Timeg) System of MedicineSECTION E - DETAILS OF CLAIMa) Details of Treatment Expensesi) Pre-hospitalisation Expensesii) Hospitalisation Expensesiii) Post-Hospitalisation Expensesiv) Ambulance chargesv) Pre-Hospitalization periodvi) Post – Hospitalization periodvii) Hospital daily cash

b) Claim Documents Submitted Check List SECTION F - DETAILS OF BILLS ENCLOSEDIndicate which bills are enclosed with the amounts in rupeesSECTION G - DETAILS IN CASE OF NON-NETWORK HOSPITALa) PANb) Account Numberc) Bank Name and Branchd) Cheque/ DD payable detailse) IFSC Code

Enter the full name of the patientTell us the gender of the patientEnter age of the patientEnter Date of Birth of patientTell us the patient’s relationship with the policyholderTell us the patient’s occupationEnter the full postal addressEnter the phone number of patientEnter the E-mail ID

Enter the name of hospitalIndicate the room category occupiedGive us details of hospitalisation/Home care expenses as applicable Enter the relevant dateEnter date of admissionEnter time of admissionEnter date of dischargeEnter time of dischargeEnter the system of medicine followed in treating the patient

Enter the amount claimed as treatment expensesEnter the amount spent before hospitalisation Enter the amount claimed as hospital expenses as per the final hospital bill Enter the amount spent after discharge from the HospitalEnter the amount claimed as expenses for an AmbulanceIndicate the no. of days for which you paid for treatment before hospitalisationIndicate the no. of days for which you paid for treatment after dischargeIndicate the no. of days for which daily cash needed during hospitalisation is claimedLet us know which supporting documents are submitted

Enter the permanent account numberEnter the bank account numberEnter the bank name along with the branchEnter the name of the beneficiary the cheque/ DD should be made out toEnter the IFSC code of the bank branch

Surname, First name, Middle nameTick Male or Female or Third GenderNumber of years and monthsUse dd-mm-yyyy formatTick the right option. If others, please specify.Tick the right option. If others, please specify.Include Street, City and Pin CodeInclude STD code with telephone numberEnter the E-mail ID

Name of hospital in fullTick the right optionTick the right optionUse dd-mm-yyyy formatUse dd-mm-yyyy formatUse hh:mm formatUse dd-mm-yyyy formatUse hh:mm formatOpen Text

In rupees (Do not enter paise values)In rupees (Do not enter paise values) In rupees (Do not enter paise values)In rupees (Do not enter paise values)In rupees (Do not enter paise values)Enter no. of daysEnter no. of daysEnter no. of days

Tick the right option In rupees (Do not enter paise values)Tick the right option

As allotted by the Income Tax departmentAs allotted by the bankName of the Bank in fullName of the individual/ organization in fullIFSC code of the bank branch in full

Corona Kavach Policy, Edelweiss General Insurance Company Limited I UIN: EDLHLIP21079V012021Page 3 of 3

a) Details of the treatment expenses claimed(i) Pre-hospitalization Expenses: ` (ii) Hospitalization Expenses: `(iii) Post-hospitalization Expenses: ` (iv) Ambulance Charges: `(v) Pre-hospitalization period: ` (vi) Post-hospitalization period: days (vii) Hospital Daily Cash in case of add on cover ` Total: `

b) The documents we’ll need Signed Claim Form Operation Theatre Notes if applicable Copy of the claim intimation, if any ECG if applicable Hospital Main bill Doctor's request for investigations Hospital Break-up bill Investigation Reports (Including CT/MRI / USG / HPE) Hospital Discharge summary Doctor’s Prescriptions or Treatment Notes Hospital Bill Payment Receipt Others like Nursing Notes or Indoor Case Papers Pharmacy Bill Any other document, please specify

Edelweiss General Insurance Company Limited, Corporate Office: 5th Floor, Tower 3, Kohinoor City Mall, Kohinoor City, Kirol Road, Kurla (West), Mumbai - 400 070, Registered Office: Edelweiss House, Off CST Road, Kalina, Mumbai -400 098, IRDAI Regn. No.: 159, CIN: U66000MH2016PLC273758, Reach us on: 1800 12000, Email: support@edelweissinsurance.com, Website: www.edelweissinsurance.com, Issuing/Corporate Office: +91 22 4272 2200, Grievance Redressal Officer: +91 22 4931 4422, Dedicated Toll-Free Number for Grievance: 1800 120 216216. Trade logo displayed above belongs to Edelweiss Financial Services Limited and is used by Edelweiss General Insurance Company Limited under license. Insurance is the subject ma�er of solicita�on.

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppressed or concealed any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / Insurer, to seek necessary medical information / documents from any hospital / medical practitioner who has treated the person for whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any other claim except the pre / post Hospitalization claim, if any.

Date:

Place: Signature of the MemberD D M M Y Y Y Y

SECTION H – DECLARATION BY THE INSURED Read declaration carefully and mention the date