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THE ORIENTAL INSURANCE COMPANY LIMITED

Regd. Office : ORIENTAL HOUSE, P. B. No. 7037, A-25/27 Asaf Ali Road. New Delhi–110 002

CLAIM FORM FOR OVERSEAS MEDICLAIM POLICY (To be submitted to below mentioned address for lodging claim)

CORIS INTERNATIONAL 8 RUE AUBER, 75009, PARIS, FRANCE

Name of Person Claiming : Mr. / Mrs. Home Address in India :

Day : __________

Time :

____________

OFFICE CODE

PLAN

CATEGORY

SERIAL NO

Occupation:

DETAILS OF POLICY

C.O. CODE

Tel No. :

_________________

Policy Number

Date – Policy Issued: Date – Trip Commenced : No. of Days : Scheduled Date of Return: Geographical Limits

Worldwide Excl. USA / CANADA

Worldwide Incl. USA / CANADA

NAME AND AGE OF EACH PERSON INCLUDED IN THE CLAIM

Mr. / Mrs. / Miss.

Initials

Surname

Date of Birth ____ / ____ / ______

DD

MM

YY

POLICY SECTION RELATING TO CLAIM (Tick Boxes)

Medical Expenses Personal Accident Loss of Checked in Baggage Delay of Checked in Baggage Loss of Passport Personal Liability

Others

DATE OF CLAIM OCCURANCE:

TRIP DESTINATION:

PLEASE COMPLETE APPROPRIATE SECTION OF CLAIM FORM AND READ CAREFULLY THE INSTRUCTIONS RELATING TO SUPPORTING DOCUMENTS REQUIRED. WHEN COMPLETED PLEASE SIGN DECLARATION : I Declare that to the best of my knowledge all particulars contained in this form are true. I also authorize Coris to obtain my medical records or information necessary to process the claim.

Signed:

Date:

Place:

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