Health TPA Pvt. Ltd IBA domiciliary Treatment Claim Reimbursement Statement ( This form should be attached along with claim FORM A) Name of the Bank VIJAYA BANK Branch Ex-Employee Policy No. Name of the Insured Employee ID Designation Vidal ID Card No. Name of the claimant Date of submission Relationship Period Sl Bill Date Description Name of Prescribed Name of the Amount Remarks No Pharmacy/Lab domiciliary claimed Name treatment amount Claimed (Signature of the Insured)
Health TPA Pvt. Ltd IBA domiciliary Treatment Claim Reimbursement Statement ( This form should be attached along with claim FORM A) Name of the Bank VIJAYA BANK Branch Ex-Employee Policy No. Name of the Insured Employee ID Designation Vidal ID Card No. Name of the claimant Date of submission Relationship Period Sl No Bill Date Description Name of Pharmacy/Lab Prescribed Name Name of the domiciliary treatment Amount claimed Remarks amount Claimed (Signature of the Insured)
dom%20claim%20statement.docx