(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)
 
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
 
Failure to call on our 24-hour helpline, in respect of Medical Accident & Sickness Claims may invalidate your claim.
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POLICY/CERTIFICATE NO.
 
Period from: to
DETAILS OF INSURED
Name:
Date of Birth:
  Sex   Male    Female  
Current Address:
Phone No. (Res)
 
Email Id.
Permanent Address:
Phone No. (Off)
 
Phone No. (Res)
Does the insured have any other Health/Accident or Travel Insurance ? If yes, please give details below:
Name of Insurer:
 
Policy Number:
 
Amount (Rs.)
Date trip commenced
 
Schedule date of return
   
Passport No.
 
Trip Destination
 
Claims Ref No.
CLAIMANT INFORMATION (If different than “Insured Information” above, Name and Age of each person included in the claim)
Name:
Date of Birth
   
Relationship with the Policyholder
Claimant’s Address
Phone No. (Off)
   
Phone No. (Res)
In what capacity are you making this claim?
Please indicate whether claim is in respect of (Tick Boxes)
Accidental Death Permanent Disablement Emergency Medical Expenses Emergency Dental Treatment
Loss of Passport Loss of Baggage Compassionate Visit Sponsor Protection
Cancer Screening & Mammography Mental & Nervous Disorder Study Interruption Personal Liability
Pregnancy Bail Bond Delay of Baggage Child Care
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.
PLACE
 
DATE
   
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.
 

Section A – Accidental Injury Form (Claimant’s Statement)

Date of accident
 
Time
 
Place of Accident
Please describe in detail the circumstances of accident (attach separate sheet if needed)
Please describe the nature of Insured’s injuries
Please list the names and addresses of all treating physicians and hospitals:
Name Street Address City State Pincode Phone
Did police or other authorities investigate the accident? If yes, please provide name, address and telephone number of all investigating
officers and agencies:
 

Section B - Emergency Medical Expenses/ Emergency Dental Expenses (Insured’s Statement)

Name of Sickness or Injury
Date of Sickness/Injury
Place of Sickness/Injury:
Circumstances of Sickness/Injury?
Nature of Sickness/Injuries:
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:
Name Address Phone No. Admitted on Discharged on
Details of Claimed Expenses Amount Charged in local currency Has bill been paid by you?
Yes No
Yes No
Yes No
Total  
 

Section C – Accidental Injury / Medical Expenses Claim (Accident or Sickness) Attending Physician’s Statement

Date of accident/sickness
 
Date of first treatment
   
Please describe in detail the nature
of the Insured’s injuries
Was the Insured hospitalized? If yes, please list the names and addresses of all hospitals and all admission/discharge dates
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
Were any surgical procedures performed? If yes, please list all procedures, and dates performed
What are the Insured’s current subjective symptoms?
What are the objective findings? (please include results of current x-rays, lab tests, etc.,)?
Dates of total disability From To
 
Dates of total partial From To
 
Date Insured able to return to work
 
Was the Insured seen by any other physician? If yes, please list the names and addresses of all other physicians
ATTENDING PHYSICIAN INFORMATION
Name of Attending Physician
Address
Phone
 
 
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
 
PLACE
 
DATE
   
 

Section D – Baggage Protection / Baggage Delay Claim Information

Date of loss, damage or delay
 
Time of day a.m. p.m.
 
   
Please describe in detail where and how the loss, damage or delay occurred
Please describe in detail the nature and extent of loss, damage or delay
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
Name of carrier
Flight, trip our tour number:
Was the carrier notified at the time of loss or damage? Yes    No
If yes, please identify where, when and to whom (name and title) notification was given
Was extra valuation of the property declared? If yes, how much?
Was the baggage checked at the time of loss or damage? Yes    No
If yes, please enclose claim check Yes    No

Has formal claim been filed against the carrier? Yes    No
If yes, has payment been made to you?   Yes    No If yes, amount received?
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
Has the claim been filed? Yes    No
If yes, what is the current status of that claim?
Was loss reported to police or other authorities? Yes    No
If yes, please identify where, when and to whom (name and title) loss was reported
Case #
 
 
Valuation of lost and/or damage property
Sr. No Description Date and place of Purchase Original Cost Replacement Cost or Estimated Amount Claimed
1.
2.
3.
4.
5.
6.
7.
(attach bills of sale, receipts or estimates)
Are any claims items used in your business / occupation or profession? . If yes, identify the items by * above
 
Name of the Common Carrier:
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
PLACE
 
DATE
   
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.
 

Section E – Sponsor Protection

The following details and documents are required along with the claim form:
Name of the sponsor
Address of the Sponsor
Submission of an official death certificate
Statement from a Physician stating cause of death
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
 

Section F – Study Interruption

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.
 

Section G – Bail Bond

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.
 
PLACE
 
DATE
   
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.
 
 

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)
 
 
 
Declaration: I
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: