(To be filled in by the Insured Policyholder or Insured’s Representative duly authorised by Power of Attorney. Issuance of this claim form is not to be taken as an admission of liability. Please attach all bills, receipts, credit card slips pertaining to your claim) |
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Please contact our 24x7 helpline in respect to any claims settlement request. |
Toll Free - + 800 08250825 |
Landline - + 91 - 120 - 4507250 (Chargeable) |
Email ID - travelclaims@hdfcergo.com |
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Failure to call on our 24-hour helpline, in respect of Medical Accident & Sickness Claims may invalidate your claim. |
Click on "Generate PDF" button and save the filled form in your desired folder.
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DETAILS OF INSURED |
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Does the insured have any other Health/Accident or Travel Insurance ? If yes, please give details below: |
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CLAIMANT INFORMATION (If different than “Insured Information” above, Name and Age of each person included in the claim) |
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Please indicate whether claim is in respect of (Tick Boxes) |
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AUTHORIZATION |
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 also authorise services provider of HDFC ERGO to obtain any medical records or information to process this claim. |
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. |
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. |
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N.B. Please complete appropriate section of Claim Form and read carefully the instructions relating to supporting documents required. When completed please sign declaration above. |
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Section A – Accidental Injury Form (Claimant’s Statement)
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Please describe in detail the circumstances of accident (attach separate sheet if needed) |
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Please describe the nature of Insured’s injuries |
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Please list the names and addresses of all treating physicians and hospitals: |
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officers and agencies: |
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Section B - Emergency Medical Expenses/ Emergency Dental Expenses (Insured’s Statement)
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If claim was due to hospitalisation was SOS Assistance contacted
Yes
No
If ‘NO’, please advise on separate sheet. |
Please list the names and addresses of all treating physicians and hospitals: |
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Section C – Accidental Injury / Medical Expenses Claim (Accident or Sickness) Attending Physician’s Statement
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Please describe in detail the nature
of the Insured’s injuries |
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Did the Insured have any injury or illness prior to the accident that contributed to the accident or to the Insured’s present condition? If yes, please describe |
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What are the Insured’s current subjective symptoms? |
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What are the objective findings? (please include results of current x-rays, lab tests, etc.,)? |
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ATTENDING PHYSICIAN INFORMATION |
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I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud |
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Section D – Baggage Protection / Baggage Delay Claim Information
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Please describe in detail where and how the loss, damage or delay occurred |
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Please describe in detail the nature and extent of loss, damage or delay |
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Was loss, damage or delay occurred while insured property was on or in the custody of a common carrier (e.g., railroad, airline, cruise ship, bus, taxi, etc.) ?
Yes
No |
If yes, please complete the following |
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If yes, please identify where, when and to whom (name and title) notification was given |
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Do you have any other insurance that may provide coverage for this accident or loss? |
If yes, please identify the name, address and policy number of all other insurance including Homeowners Travel club, credit card etc |
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If yes, what is the current status of that claim? |
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If yes, please identify where, when and to whom (name and title) loss was reported |
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Valuation of lost and/or damage property |
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I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud |
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N.B. Please complete appropriate section of Claim Form and read carefully the instructions relating to supporting documents required. When completed please sign declaration above. |
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Section E – Sponsor Protection
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The following details and documents are required along with the claim form: |
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Official invoice(s) from the educational institution and voucher(s) of payment of the said Tuition fees, shall be used for calculating any reimbursement paid by the Company |
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Section F – Study Interruption
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The following details and documents are required along with the claim form: |
Details of hospitalization regarding illness/injury suffered by the insured supported by respective copies/originals of documents duly attested by the Hospital. |
In case of death of any one immediate family member or the sponsor during the entire policy period, which leads the Insured to discontinue his / her studies for the remaining part of the current school semester for which Tuition has been paid death certificate of the immediate family member or the sponsor is required. |
The Company shall reimburse the Insured, the Tuition fees which have already been advanced to the educational institution less possible/actual refunds, up to the amount stated in the Policy Schedule. Hence details of tuition fees paid and refund received from the educational institution if any has to be provided. |
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Section G – Bail Bond
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The following documents are required along with the claim form: |
1. Copy of FIR/Remand application |
2. Copy of summons/warrant |
3. Receipt of the bail amt if paid by the insured |
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. |
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N.B. Please complete appropriate section of Claim Form and read carefully the instructions relating to supporting documents required. When completed please sign declaration above. |
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HDFC ERGO General Insurance Company Limited
Consent for Mode of Claim Payment
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(Please tick for mode of payment) |
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(All Fields are Mandatory in case of Fund Transfer) |
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In Support of Bank Details |
(Please tick the type of proof submitted) |
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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. |
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