Child Health Insurance Claim Form
Policyholder Information
Full Name
Policy Number
Date of Birth
Contact Number
Address
Child Information
Child's Full Name
Date of Birth
Gender
Male
Female
Other
Relationship to Policyholder
Treatment Details
Date of Admission
Date of Discharge
Name of Hospital/Clinic
Reason for Hospitalization
Doctor's Name
Claimed Expenses
Total Amount Claimed
Details of Expenses
Bank Details (for claim amount transfer)
Bank Name
Account Number
IFSC Code
Account Holder Name
Declaration
I hereby declare that the details provided are true & correct to the best of my knowledge.
Date
Signature