Paramount Health Services & Insurance TPA Private Limited

Certificate No : *

Unique id/LAN no: *

Name of Proposer / Loanee :*

Patient Name :*

Age :

Yrs

Gender :*

Type : *

Hospital State :

Hospital City :

Name Of Hospital :

Hospital Address :

Pincode :

Policy start Date :

Valid upto :

Type Of Loss :

Cause of Loss :

Claim Benefit :

Date of Admission: *

Date Of Discharge :

No of Days :

Estimated Amount : *

Benefit Type : *

Ailment:*

Mobile Number :

Email ID :

Remarks :

Hospital Name
Intimation Received Yes/No
Date of File Received
Date of Admission
Date of Discharge
Investigation Done
Remarks if Investigation Done
Claim Type

Preexisting Coverage Waiver	Waiting Period 30days Waiver	First Year Waiting Period Waiver	Maternity Waiting Period Waiver