FORMAT FOR INDEMNITY BOND FOR SETTLEMENT OF DUPLICATE HOSPITAL BILLS

| November 18, 2013

FORMAT FOR INDEMNITY BOND FOR SETTLEMENT OF DUPLICATE HOSPITAL BILLS

We, hereby give an undertaking that the original bills of hospital / diagnostic lab / imaging centre, the ID Nos. of which are appended are said to have been destroyed in a fire accident that took place on 11.08.2013 at UTI-ITSL New Delhi office and that we are now submitting the print outs of scanned copies of the above referred original documents/bills for consideration of payment.

We also hereby give an undertaking that no claim shall be made against original documents / bills, of which printouts of the scanned copies are submitted herewith and we agree to indemnify against any loss that may be caused to CGHS due to final settlement of these claims on the basis of printouts of scanned documents/bills and this indemnity bond. We further give an undertaking that if original bill(s) is /are found, no claim shall be made against the same and that in the event of any inadvertent payment received against original bills in future, we agree to indemnify against any loss that may have been caused to CGHS due to final settlement of these claims.

We also certify that no payment was received till date against original / duplicate bills amounting to Rs ( in words…. ) being preferred for payment along with this indemnity Bond.

Enclosed herewith a consolidated list of duplicate bills with ID Nos. and a copy of Bank Account attested by the Bank.

Authorized Signatory

Hospital / Diagnostic Lab / Imaging Centre

On Rs.100 Non-Judicial Stamp paper attested by Notary Public

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Category: CGHS, Ministry for Health and Family Welfare

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