(Issuance of this form does not amount to admission of any liability or a waiver of any of the terms and conditions of the insurance contract.)
Click on "Generate PDF" button and save the filled form in your desired folder.
 
Please give the following information correctly and completely to enable us to process your claim promptly
1. Policy Number (in full)
   
 
2. HDFC ERGO Card No.
   
(In case of Child Day 1 cover, please add the Card Number of the mother)
 
3. Name of the Insured (in whose name policy is issued)
  (First Name) (Middle Name) (Last Name)
 
4. Details of the insured person (in respect of whose claim is made)
i) Name of the Insured person:
  (First Name) (Middle Name) (Last Name)
ii) Relationship with
the Insured
iii) Date of Birth / Age DOB
Age
iv) Occupation
v) Current Residential Address & Contact Details
 
Address
City
 
Pincode
State
 
Sex:
Male Female
Tel.(Res.)
(Off.)
Mobile
E-mail
5. Have you previously from or received any treatment for the related illness? Y   N
If yes, give complete details:
6. Date on which disease or illness frst detected
 
7. Details of treatment received including dates
of outpatient or inpatient:
8. Details of the doctor
  (First Name) (Middle Name) (Last Name)
 
 
Address
City
Pincode
Qualifcation
State
 
Sex:
Male Female
Tel.(Res.)
(Off.)
Mobile
9. Please give names and contact details of all doctors whom you have consulted
 
Name
Tel.(Res.)
 
 
STD Code
 
Name
Tel.(Res.)
 
 
STD Code
 
Name
Tel.(Res.)
 
 
STD Code
 
Name
Tel.(Res.)
 
 
STD Code
 
Name
Tel.(Res.)
 
 
STD Code
10. Please tick as (√) specifying the type of Critical Illness
  1. Cancer  
  2. Coronary Artery (Bypass) Surgery  
  3. Heart Attack (Myocardial Infarction)  
  4. Kidney Failure (End Stage Renal Failure)  
  5. Major Organ Transplantation  
  6. Multiple Sclerosis  
  7. Paralysis  
  8. Stroke  
  9. Aorta Graft Surgery  
  10. Primary Pulmonary Arterial Hypertension  
  11. Heart Valve Replacement  
  12. Benign Brain Tumor  
  13. Parkinson’s Disease  
  14. Alzheimer’s Disease  
  15. End Stage Liver Disease  
11. No. of documents submitted including this CLAIM FORM
 
Declaration
I hereby warrant that:
(1) I have read and understood General Conditions 3 of this policy, and
(2) That the foregoing particulars are true and complete in all material respects, and
(3) There is no other insurance in force in respect of that may apply to this claim.
I also authorise HDFC ERGO to make payment of the claim admissible as per terms, conditions and limitations of the policy. I consent and authorise HDFC ERGO General Insurance Company or their representatives to seek medical information from any hospital/Medical practitioner who has at any time attended concerning the claim.
 
Place
 
Date
 
If any claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices, whether by You or any Insured Person or anyone acting on behalf of You or an Insured Person, then this Policy shall be void and all benefits paid under it shall be forfeited.
 
 
Check List of Enclosures for Submission of Claim
 
Duly filled and signed Claim Form
Photocopy of current year policy
Copy of discharge summary of hospitalization, if any
A medical certificate confirming the diagnosis of critical illness from a doctor not less qualifed than MD/MS
Investigation reports / other related documents reflecting the critical illness diagnosis
First consultation letter and subsequent prescriptions
Original cancelled cheque with payee name printed on the cheque is required. If name of payee is not printed on the cheque please attach copy of the first page of bank passbook
 

HDFC ERGO General Insurance Company Limited

Consent for Mode of Claim Payment
 
Cheque    Fund Transfer(Please tick for mode of payment)

(All Fields are Mandatory in case of Fund Transfer)

Cancelled Cheque    Bank Passbook CopyIn Support of Bank Details
(Please tick the type of proof submitted)
*Copy of cancelled cheque with payee name printed. If name of payee is not printed, on the cheque please attach copy of the first page of bank passbook

undersigned, legal beneficiary of the above claim, declare that all details mentioned in this form are true and I agree to the mode of payment against the particular claim number mentioned above.
 
 

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&TGeneral Insurance Company Limited upto Sept 13, 2016). CIN: U66030MH2007PLC177117. Registered & Corporate Office: st1Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HDFC ERGO General Insurance Company Ltd. displayed above belongs to HDFC LTD and ERGO International AG and used by HDFC ERGO General Insurance Company under license. Toll-free: 1800 2 700 700 | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com.UIN:HDFHLIP10002V010910. IRDAI Reg No. 146.