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INSURED INFORMATION

Period of Insurance To:

ACCIDENTAL DEATH & PERMANENT DISABILITY

Particulars of the accident /Description of accidental details   

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

Whether reported to Police station    Y    N

If yes, police station Name   

In case hospitalized list the name and address of all treating physicians and hospital   

Please indicate whether claim is in respect of (tick boxes)    Accidental Death    Permanent Total Disability

For child education Benefit: Provide details of dependent child (If applicable)

For Permanent Total Disability

Details of permanent disablement:  

ACCIDENTAL HOSPITALIZATION / HOSPITAL CASH

Particulars of the accident /Description of accidental details    

Please describe the nature of Insured’s injuries:  

Name and address of all treating physicians and hospital   

Whether reported to Police station    Y    N

If yes, police station Name   

TEMPORARY TOTAL DISABLEMENT /BROKEN BONES /ACCIDENTAL INJURY

Particulars of the accident /Description of accidental details    

Whether reported to Police station    Y    N

If yes, police station Name   

Details of Temporary disablement  

Name and address of all treating physicians and hospital   

Date Insured able to return to work:  

CLAIMANT INFORMATION - INSURED OR NOMINEE (NOMINEE ONLY IF INSURED IS EXPIRED)

Cheque    Fund Transfer(Please tick for mode of payment)
Please fill in the fund transfer details

(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)

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.

Individual Personal Accident- Claim Document Checklist(Additional documents if required will be requested by the insurer)

*Photocopy of Aadhaar Card /Aadhaar Card number is mandatory for all claims
Personal Accident - Death

  • Duly filled and signed Claim Form
  • FIR from Police station/ Medico legal certificate from hospital (MLC Copy)
  • Post Mortem Report, Inquest Panchnama
  • Cause of death Certificate from treating doctor
  • Death Certificate from Municipal Corporation
  • Histopathology or Chemical viscera or blood analysis report from the hospital (If done)
  • KYC form and KYC documents (ID and address proof e.g Pan card/Aadhaar card/Ration card/Passport etc.)
  • Original cancelled cheque with name of Nominee printed on cheque is required. If name is not printed on cheque please attach first page of bank passbook / Bank statement with stamp

Personal Accident - Permanent Disability

  • Duly filled and signed Claim Form
  • FIR from Police station/ Medico legal certificate from hospital (MLC Copy)
  • Disability Certificate from Government Hospital
  • All treatment papers and Investigation report from hospital
  • Photograph with disable part
  • KYC form and KYC documents (ID and address proof e.g Pan card, Aadhaar card, Ration card, Passport etc.)
  • Original cancelled cheque with Payee name (Insured) name printed on cheque is required. If name is not printed on cheque please attach first pageof bank passbook/Bank statement with bank stamp

Accidental Hospitalization Benefit /Hospital cash benefit

  • Duly filled and signed claim form
  • FIR from Police station/ Medico legal 3.certificate from hospital (MLC Copy)
  • Copy of discharge summary of hospitalization, if any
  • KYC form and KYC documents (ID and address proof e.g Pan card, Aadhaar card, Ration card, Passport etc.)
  • Original Hospital Final Bill with payment receipt, Original Medicine Bills, Prescriptions. Original Investigation reports and bills
  • Original cancelled cheque with Payee name (Insured / Nominee) name printed on cheque is required. If name is not printed on cheque please attach first page of bank passbook /Bank statement with bank stamp

Temporary total disablement /Broken bones /Accidental injury

  • Duly signed filled claim form
  • Discharge card / summary from hospital
  • Investigation report like X-RAY/ MRI / CTscan etc if any
  • Fitness certificate from treating doctor
  • Leave certificate from employer (If or are salaried) or ITR of last 2 yrs if business men
  • KYC form and KYC documents (ID and address proof e.g Pan card, Aadhaar card, Ration card, Passport etc.)
  • Original cancelled cheque with Payee name (Insured) name printed on cheque is required. If name is not printed on cheque please attach first page of bank passbook / Bank statement with stamp