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

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

@csrf

Step 1

CLAIM INTIMATION DETAIL

Intimation Date

Policy Number

Policy Holder Name

Insurance Company Name

Admission Date

Incident Date

Incident Address

Short Detail Of Incident

Reason Of Incident

Patient Name

Hospital Name

Vehicle Name

Vehicle Number

Reason Of Admission

TP Due Date

Segment

Life Insurance Plan Name

Broker Name

Sub Agent Name

Agency Name

Policy Holder Name

Insurance Company Name

Branch Name

Death Person Name

Death Of Date

Sum Assured

Term Rider Sum Assured

Accident Sum Assured

Double Accident Sum Assured

Step 2

REGULAR SETTLEMENT ENTRY

<-- There is Raising Query Then Settled -->

Transaction Date*

Document Number*

Query Raising Date

Query Answer Submision Date

Date Of Discharged

Date Of Incident

Claim Lodged

Claim Lodged Amount

Source Of Settlement Detail*

Settlement Date*

Claim Settled Amount*

Differance Amount

Reason Of Deduction

Amount Paid / Reciept Date

{{--

Final Accepted*

Deduction Claim

Rejected Claim

Going To Court

Court Settlement

--}} {{--

Deduction Claim Date

Deduction Claim Received Date

Claim Rejected Date

Reason Of Claim Rejection

Going To Court Case

Yes

Remarks

Amount Received By Client Date

--}}

Sr No*

Claimed Details

Amount Rs.

Claim Recieved Amount

Differance Amount

Differance Reason

Deduction from Claim Details

Remarks

Step 3

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

Claim Document Type*

This value is required.

Claim Document Name*

This value is required.

Upload Document(JPG, PNG, JPEG or PDF)*

Nos

@endif

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