CLAIM FORM MEDICAL INSURANCE THE ORIENTAL INSURANCE CO LTD M C D O 16 Magnet House 4th floor

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CLAIM FORM MEDICAL INSURANCE THE ORIENTAL INSURANCE CO LTD M C D O 16 Magnet House 4th floor Powered By Docstoc
					                                            CLAIM FORM_MEDICAL INSURANCE




                                 THE ORIENTAL INSURANCE CO. LTD.
              M.C.D.O. 16, Magnet House, 4th floor, N.M. Marg, Ballard Estate, Mumbai 400 001.
         Tel. 022-22619241/5154 , fax 022- 22619243. email. mcdo16111700@orientalinsurance.co.in
               CLAIM FORM FOR MEDICAL INSURANCE - XTRAPOWER FLEET CARD PROGRAM


2    Name of the Owner                                        :

     Claimant i.e. Fleet owner/driver/co-driver/Helper cum
3                                                             :
     cleaner

     If Claimant is the Owner the Vehicles under which the
4                                                             :
     claim is lodged

5    Customer ID                                              :

6    Card PAN No.                                             :

7    Regn. No. of the Vehicle/Vehicles involved               :

8    Date & Time of Accident                                  :

9    Place of Accident                                        :

10   Cause of Accident                                        :

11   Nature of Injury                                         :

     Name, Place & Regn. No. of Hospital/Name & address
12                                                            :
     of attending Doctor

13   Amount claimed                                           :




Counter signature of Owner of Vehicle, if claimant not the
                        owner                                              Signature of Claimant




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