@extends('reachassuree_agent/layouts.main') @section('title', $data['title']) @section('content')

@include('../reachassuree_agent/master/comman/header')

@csrf

Step 1

Choose Claim Type*

Non Cash

Cashless

Choose Claim Intimation Type*

Mediclaim

Vehicle Claim

Death Claim

Disability Claim

Other Claim

Vehicle Claim Owner Type*

Own Vehicle Claim

Third Party Vehicle Claim

Select Agency*

Self Agency

Others Agency

Select Claim Type*

This value is required.

Select Death Claim Type* {{-- --}}

This value is required.

Client Type*

This value is required.

Select Policy Holder Name*

This value is required.

Policy Holder Name*

Select Insurance Company*

This value is required.

{{--

Select Branch*

This value is required.

--}}

Select Vehicle Number*

This value is required.

Select Policy Number*

This value is required.

Policy Number*

Claim Count

Policy Type*

This value is required.

Step 2

Mediclaim

POLICY DETAIL

Policy Number

Policy Holder Name

Insurance Company Name

Nominee Name

Nominee Contact No.

Branch Name

Branch Name

Vehicle Name

Vehicle Number

Segment

Broker

Sub Agent

Agency

Plan No./Term/Prem.Term

Plan Name

Premium Due Date

Risk From Date

Risk To Date

Sum Assured

Remaining Assured Amt

Person Covered

Premium Amount

Bank Name

Model

RTO

Policy Holder Address

Policy Holder Name

Insurance Company Name

{{--

Branch Name

--}}

{{--

--}}

Claim Intimated Branch* {{--

This value is required.

--}}

{{--

--}} {{--

--}}

Sum Assured

Insurance Company*

This value is required.

Address / City / Pin*

Risk From Date*

Risk To Date*

Segment Name*

This value is required.

Policy Sum Assured*

Agency*

This value is required.

Broker*

This value is required.

Sub Agent*

This value is required.

Mobile No.*

Whatsapp No.*

Contact Person Name*

Policy Address*

Present Address*

Email Id*

Step 3

Mediclaim

CLAIM INTIMATION ENTRY

Transaction Date*

Document Number*

Policy Holder Name

Patient Name*

This value is required.

Selected members in policy are displayed here.

Patient Name*

Admission Date*

Incident Date*

Incident Time* {{-- --}}

Death Person Name*

Nominee Name*

This value is required.

Contact Number*

Intimation Date*

Estimated Loss Amount*

Date Of Birth

Age

Gender*

This value is required.

Full Postal Address

Job Joining On

Job Description

Approx Salary

Death Date*

Death Type*

This value is required.

Reason Of Death*

This value is required.

Destination Of Accident

Illness Name

Death Short Detail

Intimated To

Firm / Person Name

Hospital Name / Address

Destination Of Death

Police Station Name

Hospital Name*

Hospital Contact No.

Land Line / Toll Free No.

Hospitalized Reason*

Hospital Address*

Estimated Stay Days

Estimated Expense

Mediclaim Insurance Company Name

Mediclaim Policy Number

Mediclaim Sum Assured

Short Detail Of Incident*

Incident Address*

Incident Contact No.*

Incident Date*

Incident Time {{-- --}}

Reason Of Incident*

This value is required.

Intimation To Police Station*

This value is required.

Intimation To Fire Station*

This value is required.

Garage Name

Garage Address

Garage Contact Number

Estimated Expense

Vehicle Driving By*

Relation*

This value is required.

Incident Short Detail*

Damage Short Detail*

@if($data['multiple_claim'] == 1 || $data['data']['claim_parent_id'] != 0)

Claim Settled

Yes

No

Claim Settled Date*

Claim Settled Amount*

@endif

Intimated Through

Email

Online

Call Center

Whatsapp

Others

Intimation To…

Direct Company

This value is required.

This value is required.

Add Email

TPA Company

Please select atleast one of this checkbox.

This value is required.

This value is required.

Add Email

Intimated By

Agent

Office Staff

Policy Holder

Policy Holder Contact Number

Remarks

Step 4

@if($data['can_edit'] == 0 && $data['multiple_claim'] == 0)

Claim Document Type {{--

This value is required.

--}}

Claim Document Name {{--

This value is required.

--}}

Upload Document(JPG, PNG, JPEG or PDF)

Nos

@endif

Insurance Company Email

@csrf

Status*

This value is required.

Company Email*

E-Mail Contain

Branch

@csrf

Branch Name*

@if(getActualExpirationDate() >= date('Y-m-d H:i:s')) @else

Your current plan has expired. To resume disabled operations, you have the option to renew your existing plan or upgrade to a new one. Simply visit our 'Renew' or 'Upgrade' tab to proceed.

@endif

@endsection @section('custom-scripts') @endsection