Notification of Physical Loss or Damage
(The issue of this form is not to be taken as an Admission of Liability)
PLEASE ANSWER ALL QUESTIONS FULLY

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DETAILS OF INSURED

   
 

DETAILS OF OTHER INSURANCES

 
 
 
 
 
NB: If Insurance is effected with other Companies, copies of such Policies to be attached.

DETAILS OF LOSS

  

Was the accident related to the Insured’s occupation?    Y    N

I/We hereby agree, affirm and declare that.

  • The statements/information given stated by me/us in this claim form are true, correct and complete.
  • The details of all persons having an interest in the property in respect of which the claim is being made are provided as per the proposal form or by way of any endorsement in the policy. Furthermore save and expect as provided or disclosed in this claim for, no claim made hereunder (or the same/similar claim) has beed made or lodged with any other insurance company.
  • No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim has been withheld or not disclosed.
  • If I/We have given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner failed to disclose material information, the policy shall be void and that I/We shall not be entitled to all/any rights to recover there under in respect of any or all claims, past, present or future.
  • The receipt of this claim form/other supporting/related documents does not constitute or be deemed to constitute an agreement by the company of the claim and the company reserves the right to process or reject or require further/ additional information in respect of the claim.

I/We hereby understand, declare, consent and authorise the Company that personal health details, medical history and financial information, as provided to he Company may be utilised for processing the claim made under the Policy. I/We hereby also understand, declare and consent that the Company shall have right to retain and disseminate the same to any service provider for providing services related to insurance.

 

HDFC ERGO General Insurance Company Limited

Consent for Mode of Claim Payment

 
Name of Insured
Policy Number
 
Claim Number
 
Beneficiary Name
Mode of Payment Cheque    Fund Transfer
(Please tick for mode of payment)
 
 
(All Fields are Mandatory in case of Fund Transfer)
Insured’s Name as per Bank Account
Bank Account Number
 
Branch Name
 
IFSC Code
Email address
Attachments Cancelled Cheque    Bank Passbook Copy
In Support of Bank Details
(Please tick the type of proof submitted)
*Physical copy of cancelled cheque with payee name printed is required. 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.
 
 
 
 
Date: