(The issue of this form is not to be taken as an admission of Liability)

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DETAILS OF INSURED

 
 
 
 
 
Period of Insurance To:

PLEASE INDICATE WHETHER CLAIM IS IN RESPECT OF SECTIONS

Critical Illness
Personal Accident
Accidental Hospitalization Benefit
Loss of Job
Credit Shield
Householder’s Coverage
Garage Cash
Permanent Total Disability/Permanent Partial Disability

CRITICAL ILLNESS

Select one of the below against which claim is being made

Heart Attack (Myocardial Infarction)
Coronary Artery Bypass Surgery
Stroke
Cancer
Aorta Graft Surgery
Kidney Failure
Major Organ Transplantation
Multiple Sclerosis
Paralysis
Primary Pulmonary Arterial Hypertension
Details about onset, duration and diagnosis of disease/ sickness/ illness  
Place of Sickness/Injury/Accident  

Please list the names and addresses of all treating physicians and hospitals

Name
Street Address
City
 
Pincode
 

PERSONAL ACCIDENT & CREDIT SHIELD

Particulars of the accident / Description of accidental details     

Insured's Profession   

Names and addresses of treating physicians and hospitals

Name
Street Address
City
 
Pincode
 

Whether reported to Policy station    Y    N

If Yes Police station Name   

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

For Permanent Total Disability/Permanent Partial Disablility

Details of permanent disablement:  

ACCIDENTAL HOSPITALIZATION BENEFIT

Particulars of the accident / Description of accidental details     

Names and addresses of treating physicians and hospitals

Name
Street Address
City
 
Pincode
 
Does the Insured have any other Insurance?   Yes   No     If Yes , Attach list of details with type of policy and sum insured details

Whether reported to Policy station    Yes    No

If Yes Police station Name  

LOSS OF JOB

Name of the Employer
Employer Address
City
  State
Pincode
  Companies HR Email id
Designation
  Department
Date of Joining the Organization
  Date of Termination / Suspension
Cause of termination / suspension
 
 

HOUSEHOLDER COVERAGE

Nature and Cause of Loss (Please describe the circumstances leading to the loss)

If insured is not sole owner, the nature of his/their Interest in the property and details of other interests

Whether Loss intimated to i) Police   Yes   No        ii) Fire Brigade   Yes   No     (Copies of the FIR Report to be submitted.)

Affected Property/Damaged Items

Estimated Loss (Repairs/ Replacement Cost if available)

Please Attach your Detailed Claim Bill & Supporting Documents with Claim Form

GARGE CASH

Date of Car delivered to Insured

CLAIMANT INFORMATION (IF DIFFERENT THAN "INSURED INFORMATION") ABOVE

I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge regarding the insured to release any information requested regarding this claim and the loss reported. I understand this information will be used by HDFC Ergo General Insurance, or its authorized representatives, for the purpose of evaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim.

I understand that any person who knowingly and with intent to defraud or deceive any insurance company fles a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud.

I hereby declare that the particulars furnished above are true and correct to the best of my knowledge.

I/We hereby understand, declare, consent and authorise the Company that personal health details, medical history and financial information, as provided to the 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.

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.

Sarv Suraksha - 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
Major Medical Illness (Critical Illness)

  • Duly filled and signed Claim Form
  • Documents required from the Hospital:
    • Copy of discharge summary of hospitalization, if any
    • A medical certificate confirming the diagnosis of Critical illness from a doctor not less qualified than MD/MS
    • Investigation Reports and other related documents reflecting Critical Illness diagnosis (Original)
    • First consultation letter and subsequent prescriptions
  • Outstanding Loan Statement from HDFC Ltd/HDFC Bank
  • 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 of Insured or Nominee (If insured is expired/died), 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

Accidental Hospitalization Benefit

  • Duly filled and signed claim form
  • FIR from Police station/ Medico legal
  • 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

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

Credit Shield

  • All documents of PAAccidental Death
  • EMI Repayment schedule from HDFC LTD/HDFC bank

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
  • Outstanding loan statement from the HDFC Ltd
  • 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 page of bank passbook/Bank statement with bank stamp

Dependent Child Education Benefit

  • All documents of PAAccidental Death
  • Ration Card Copy/Birth Certificate
  • Certificate from the school/college where dependent child is studying/Fee receipt of school & collage
  • School ID card

House Holder Coverage
Theft / Burglary
Duly filled and signed claim form

  • Police FIR copy
  • Police Final Report Copy
  • List of theft/stolen items with Cost
  • Bills/Invoice of items theft/stolen
  • 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

Fire

  • Claim Form duly filled & signed.
  • Copy of FIR and complaint letter to Police Authorities mentioning the loss incident in detailed, if filed with police authorities.
  • Copy of claim intimation to insurer.
  • Your claim bill mentioning Items Claimed, Quantities Claimed and their Rates, along with repair/reinstatement cost supporting & proof of payment.
  • Fire Brigade Report in case it is summoned and if not the reason for the same.
  • Supporting documents such as Fixed asset register giving the capitalization details in order to arrive at the Value At Risk at the time of loss.

Loss of Job

  • Duly filled and signed claim form
  • Copy of Termination letter issued from the employer with the reason for termination/suspension/dismissal/retrenchment
  • Copy of Appointment letter of the last organization from where termination has been done along with the terms and conditions of employment
  • EMI confirmation statement from HDFC LTD / HDFC Bank LTD from where the loan is granted. New employment letter
  • If currently employed, then new employment letter along with the terms and conditions of employment
  • Last three months salary slips
  • Copy of Outstanding Loan/Bank Statement from HDFC Ltd
  • 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

Garage Cash

  • Duly filled and signed claim form.
  • Copy of Motor insurance policy
  • RC copy
  • Copy of surveyor's report from motor insurance company
  • Copy of repair bill
  • Copy of repair estimates /Job Card (Vehicle in-date & Vehicle out-date)
  • Copy of driving license