CLAIM INTIMATION
To, Date:
The Divisional Manager
United India Insurance Company Ltd.
Divisional Office
M. C. Road
Tezpur
Policy No: 13070048/ ……………......................................... Sum insured: ……………………………
Policy issuing office……………………………………………………………………………………….
Period of insurance from: ……………………………….. to: …………………………………………...
Name of the insured & address: TEZPUR UNIVERSITY, NAPAAM, TEZPUR
Name of the patient: ………………………………………………………. Roll No: …………………..
Programme/Class: ………………………………………………………………………………………...
Registration No/Roll No: …………………………………………………………………………………
Name of the disease/illness contracted or injury suffered: …………………………………………..
……………………………………………………………………………………………………………….
Date of illness: ……………………………………………………………………………………………...
Name of the Medical Practitioner of Tezpur University: ……………………………………………...
Referred by:
Signature of the claimant
Signature of the authority
Tezpur University