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user_data2.php
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<?php
include("includes/user_header.php");
$uname1 = $_SESSION['username'];
//echo $uname1;
$query = "SELECT * FROM dependents WHERE u_email = '$uname1' ";
$query1="SELECT * FROM form_details where user_id = '$uname1' ";
$result1=$conn->query($query1);
$result = $conn->query($query);
while($row = mysqli_fetch_assoc($result))
{
$d_name = $row["d_name"];
$relation_name = $row["relation_name"];
$d_relation=$row["d_relation"];
$d_occupation=$row["d_occupation"];
$d_address=$row["d_address"];
$d_age=$row["d_age"];
$d_mobile=$row["d_mobile"];
}
while($row1 = mysqli_fetch_assoc($result1)){
$user_id = $row1["user_id"];
$illness_nature = $row1["illness_nature"];
$treatment_st_date = $row1["treatment_st_date"];
$treatment_end_date = $row1["treatment_end_date"];
$doctor_name = $row1["doctor_name"];
$doctor_address = $row1["doctor_address"];
$doctor_phone_no =$row1["doctor_phone_no"];
$registration_no =$row1["registration_no"];
}
?>
<div class="row " style="position: relative; margin-top:3%;" id="personal-form">
<div class="row">
<div class="col l1 offset-l2 center-align">
<img src="img/download.png" class="logo-image">
</div>
<div class="col l6 center-align">
<p class=""><h5 class="logo-header">THE NEW INDIA ASSURANCE COMPANY LIMITED</h5>
D.O 110800, JAIN TOWER,10<sup>TH</sup> & 11<sup>TH</sup> FLOOR, 17 MATHEW ROAD.,<br>
OPP.ROXY CINEMA, OPERA HOUSE, MUMBAI, 400004.</p>
<hr>
</div>
</div>
<br>
<style type="text/css">
.personal-data-table tr, .personal-data-table td{
border: 1px black solid;
}
</style>
<div class="col l8 offset-l1 "><div>
<p class="center-align" style="padding:10px;border:3px solid black; margin-right:20px; font-size:25px">OPD CLAIM FORM</p>
</div>
<h6>Issuance of this form does not amount to admission of any liability under the claim on the part of the <br>Insurers.</h6>
<h6>Please give the following information correctly and completely to enable the Company .to process <br>your
claim promptly;</h6>
<br>
</div>
<div class="col l8 offset-l2">
<div class=" row ">
<div class="col l10">
<table class="personal-data-table" >
<tbody>
<tr>
<td >1</td>
<td colspan="2"> Name of the Insured (in whose name policy is issued) </td>
<td>:</td>
<td><?= $d_name;?></td>
</tr>
<tr>
<td >2</td>
<td colspan="2"> Details of the Insured person (in respect of
whom claim is made) </td>
<td>:</td>
<td><?= $relation_name;?></td>
</tr>
<tr>
<td></td>
<td style="width: 3%;">(a)</td>
<td >Name & relationship to the Insured </td>
<td>:</td>
<td><?= $d_relation;?></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(b)</td>
<td> Present completed age </td>
<td>:</td>
<td><?= $d_age;?></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(c)</td>
<td> Occupation </td>
<td>:</td>
<td><?= $d_occupation;?></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(d)</td>
<td> Residential address</td>
<td>:</td>
<td><?= $d_address;?></td>
</tr>
<tr>
<td>3</td>
<td colspan="2"> Policy no.</td>
<td>:</td>
<td>11080034170400000005</td>
</tr>
<tr>
<td>4</td>
<td colspan="2"> Nature of disease/illness contracted or
injury suffered
</td>
<td>:</td>
<td><?= $illness_nature;?></td>
</tr>
<tr>
<td>5</td>
<td colspan="2"> Date of injury sustained or Diseases/illness
first detected
</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td>6</td>
<td style="width: 2%;">(a)</td>
<td > Name & address of the attending
Medical Practitioner
</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(b)</td>
<td> Registration no.</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(c)</td>
<td> Qualification & Tel. no.</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td>7</td>
<td style="width: 2%;">(a)</td>
<td> Name & address of the
Hospital/Nursing Home
</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(b)</td>
<td> Registration no.</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(c)</td>
<td> Date of Admission</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(d)</td>
<td> Date of Discharge</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td>8</td>
<td colspan="2"> If the claim is for OPD, please indicate</td>
<td>:</td>
<td></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(a)</td>
<td> Date of commencement of treatment</td>
<td>:</td>
<td><?= $treatment_st_date;?></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(b)</td>
<td> Date of completion of treatment</td>
<td>:</td>
<td><?= $treatment_end_date;?></td>
</tr>
<tr>
<td></td>
<td style="width: 2%;">(c)</td>
<td> Name & Address of attending Medical
Practitioner
</td>
<td>:</td>
<td><?= $doctor_name;?><br><?= $doctor_address;?><br></</td>
</tr>
<tr>
<td>9</td>
<td colspan="2"> Telephone no.</td>
<td>:</td>
<td><?= $doctor_phone_no;?><br></</td>
</tr>
<tr>
<td>10</td>
<td colspan="2"> Registration no.</td>
<td>:</td>
<td><?= $registration_no;?><br></</td>
</tr>
</tbody>
</table>
<div class="col s11 offset-l1">
<h6 class="center-align">I have incurred on the treatment of Disease/illness/accident referred of above, the expenses as per the _________ given by me in the Schedule of Expenses given overleaf.</h6><br><br>
<h6 class="center-align ">I hereby warrant the truth of foregoing particulars in every respect and I agree that if I have made or shall make any false or untrue statements, suppression or concealment, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other Medical Scheme or Insurance.
Dated at ____________ this ____________ day of ____________ 20
</h6>
<br><br><br><br><br></div>
<h6 class="logo-header">Signature of the Claimant</h6>
</div>
</div>
</div>
</div>
</div>
<div class="center-align">
<a class="waves-effect waves-light btn" onclick="printDiv()" style="overflow: hidden;">Print</a>
</div>
</div>
<br><br>
<script type="text/javascript">
$(document).ready(function() {
});
function printDiv() {
var printContents = document.getElementById('personal-form').innerHTML;
var originalContents = document.body.innerHTML;
document.body.innerHTML = printContents;
setTimeout(() => {
window.print();
document.body.innerHTML = originalContents;
}, 100);
}
</script>
<?php
include("includes/footer.php");
?>