{"id":1014,"title":"PERSONAL ACCIDENT POLICY (INDIVIDUAL) CLAIM FORM","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/Individual_Personal_Accident_Policy_Claim_Form_7ebbb475f0.pdf","sha256":"1c7f301d4ff7aae04c72a41ea0c55bbf662f8f0ce82c82ea11b0524c4ed09960","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for claiming compensation under an individual personal accident insurance policy. It is filled by the claimant (insured person) and their medical attendant.","notes":["This form is issued without admission of liability.","No claim can be admitted unless a medical report is furnished at the claimant's expense.","Total disablement means wholly prevented from attending to business/occupation.","Partial disablement means prevented from attending to a substantial portion of business/occupation."],"title":"PERSONAL ACCIDENT POLICY (INDIVIDUAL) CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant Details and Accident Information","fields":[{"help":"Enter the claim number if available","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your full name","type":"text","label":"Name in Full","options":[],"required":true,"pdf_field":""},{"help":"Enter your residential address","type":"text","label":"Residence","options":[],"required":true,"pdf_field":""},{"help":"Enter your business address if applicable","type":"text","label":"Business Address","options":[],"required":false,"pdf_field":""},{"help":"List all your permanent businesses or occupations","type":"text","label":"Permanent Business or Occupation if more than one state all","options":[],"required":false,"pdf_field":""},{"help":"Enter your age in years","type":"number","label":"Present Age","options":[],"required":true,"pdf_field":""},{"help":"Enter your height in feet and inches","type":"text","label":"Height","options":[],"required":false,"pdf_field":""},{"help":"Enter your weight in stones and pounds","type":"text","label":"Wt.","options":[],"required":false,"pdf_field":""},{"help":"Provide exact day, date and time of accident","type":"text","label":"When did the accident occur? State day, date and hour","options":[],"required":true,"pdf_field":""},{"help":"Provide location of the accident","type":"text","label":"Where did it occur?","options":[],"required":true,"pdf_field":""},{"help":"Describe cause of accident and injuries in detail","type":"text","label":"Give full particulars of the cause and the injuries sustained.","options":[],"required":true,"pdf_field":""},{"help":"Provide witness details if any","type":"text","label":"Give name and address of the witness of the accident.","options":[],"required":false,"pdf_field":""},{"help":"List doctors who treated you for the injury","type":"text","label":"Give name and address of the Doctors who attended you.","options":[],"required":true,"pdf_field":""},{"help":"Provide details of your regular doctor","type":"text","label":"Name and address of your ordinary Medical Attendant.","options":[],"required":false,"pdf_field":""},{"help":"Provide place and time for company officer visit","type":"text","label":"State where and when a Medical or other officer of the Company can visit you, if necessary.","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days confined and the period (from-to)","type":"text","label":"State the number of days you have been necessarily and entirely confined to Bed, Room or House as the sole and direct result of the Injuries sustained.","options":[],"required":true,"pdf_field":""},{"help":"Estimate remaining confinement duration if applicable","type":"text","label":"If still confined, state probable duration of confinement.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you worked during confinement","type":"yes-no","label":"Have you in any way attended to business or work during the above period?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if you could attend any work","type":"yes-no","label":"Have you been able to attend to any portion of your business or occupation?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details of any previous claims","type":"text","label":"Have you previously claimed or received compensation under an Accident and/or Sickness Policy? If so, give Particulars.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you have other insurance","type":"yes-no","label":"Are you insured elsewhere?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"List other insurers and claim amounts","type":"text","label":"If so give the name of each Company or Insurer and the amount you are entitled to Claim.","options":[],"required":false,"pdf_field":""},{"help":"Enter the amount claimed per week or total","type":"text","label":"I claim to be paid sum of………………..per week, or the total sum of …………which I agree to accept in full settlement of my claim on the company.","options":[],"required":true,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Dated","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Report","fields":[{"help":"Enter policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter claim number","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's full name","type":"text","label":"CLAIMANT Name in full","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Describe injuries and specify side if limb affected","type":"text","label":"The nature and extent of injuries (if to a limb, state whether right or left)","options":[],"required":true,"pdf_field":""},{"help":"Describe cause of accident as known","type":"text","label":"The cause of the accident, so far as known to you.","options":[],"required":true,"pdf_field":""},{"help":"Provide details of first medical attendance","type":"text","label":"Details of your first attendance upon him in consequence of the injuries sustained?","options":[],"required":true,"pdf_field":""},{"help":"Indicate if still treating the claimant","type":"yes-no","label":"Are you still in attendance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide relationship and history with claimant","type":"text","label":"Are you his usual Medical Attendant and if so, how far have you known him and for what have you attended him?","options":[],"required":false,"pdf_field":""},{"help":"Select the applicable cause of symptoms","type":"choice","label":"Are his symptoms (i) due exclusively to the accident or (ii) traceable to disease, infirmity or any other cause?","options":["(i) due exclusively to the accident","(ii) traceable to disease, infirmity or any other cause"],"required":true,"pdf_field":""},{"help":"Provide relevant medical history","type":"text","label":"Has he ever suffered from Gout, Rheumatism, diabetes or fits?","options":[],"required":false,"pdf_field":""},{"help":"Provide any relevant medical history affecting recovery","type":"text","label":"Is there anything in his medical history which may have contributed directly or indirectly to the accident or which may be likely to retard his recovery?","options":[],"required":false,"pdf_field":""},{"help":"State if claimant was intoxicated at accident time","type":"text","label":"Have you any reason to suppose that he was under the influence of intoxicants at the time of accident?","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days confined and period (from-to)","type":"text","label":"State the time within your own knowledge that the Claimant has been, as the direct and sole consequence of the injuries sustained, necessarily confined to his house.","options":[],"required":true,"pdf_field":""},{"help":"Estimate remaining confinement duration if applicable","type":"text","label":"If still so confined state the probable duration of confinement too.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claimant could attend work","type":"yes-no","label":"Has he been able to attend any portion of his business or occupation?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Date claimant resumed work if applicable","type":"date","label":"If so from what date?","options":[],"required":false,"pdf_field":""},{"help":"Estimate dates for partial and full recovery","type":"text","label":"If not, please state probable date (i) Of his being so able (ii) Of his complete recovery","options":[],"required":false,"pdf_field":""},{"help":"State current disability status or recovery date","type":"text","label":"Is there now any disability? If not, please give date of recovery.","options":[],"required":false,"pdf_field":""},{"help":"Additional comments by medical attendant","type":"text","label":"Any further remarks","options":[],"required":false,"pdf_field":""},{"help":"Medical attendant's signature","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Medical attendant's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Medical attendant's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Date of signing medical report","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant's medical attendant"}],"deadlines":["Form must be completed and returned within 7 days after its receipt"],"applies_to":"Individual Personal Accident Policy claims","attachments":["Medical report completed by claimant’s Medical Attendant"],"declarations":["The claimant declares the truth of the particulars and understands that false statements will forfeit the claim.","The medical attendant certifies the correctness of the medical report and accident details."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/oriental-insurance/1014-personal-accident-policy-individual-claim-form"}