{"id":1040,"title":"CLINICAL TRIALS AND/OR HUMAN VOLUNTEERS STUDIES INSURANCE POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"raheja-qbe-general-insurance","name":"Raheja QBE General Insurance Co. Ltd."},"source_pdf":"https://rahejaqbe.com/uploads/images/clinical-trials/pdf/download/claim-form.pdf","sha256":"8632b576326b5eb95c9c6423ac09c104ac3a674c199a2f414ff18f2a35224c78","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons to claim insurance under the Clinical Trials and/or Human Volunteers Studies Insurance Policy issued by Raheja QBE General Insurance Company Limited.","notes":["If space is insufficient, attach separate sheets.","The issue of this form is not an admission of liability."],"title":"CLINICAL TRIALS AND/OR HUMAN VOLUNTEERS STUDIES INSURANCE POLICY CLAIM FORM","submit":{"to":"Raheja QBE General Insurance Company Limited","how":"","address":"Commerz, 10 Floor, International Business Park, Oberoi Garden City, Western Express Highway, Goregaon(E) Mumbai – 400 063"},"purpose":"claim","sections":[{"title":"I. INSURED PERSONS’ DETAILS","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Start date of insurance coverage","type":"date","label":"Period of Insurance: From","options":[],"required":null,"pdf_field":""},{"help":"End date of insurance coverage","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Maximum coverage amount","type":"amount","label":"Limit of Liability","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"II. PARTICULARS OF CLAIM","fields":[{"help":"Date when claim notice was received","type":"date","label":"Date of receiving notice of claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the circumstances leading to the claim","type":"text","label":"Brief description of the claim circumstances","options":[],"required":null,"pdf_field":""},{"help":"Date when you first knew about the claim circumstances","type":"date","label":"When did you first become aware of the circumstances of the claim?","options":[],"required":null,"pdf_field":""},{"help":"Date when claim was first reported to the insurer","type":"date","label":"When was the claim first notified to Raheja QBE?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"III. DETAILS OF OTHER INSURANCES","fields":[{"help":"List other insurance policies covering this loss","type":"text","label":"Give details of other insurances, if any, that may cover the current loss","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"IV. DETAILS OF PREVIOUS LOSSES","fields":[{"help":"Provide information on previous claims related to this or similar policies","type":"text","label":"Give details of all previous claims under the policy mentioned at III. above or a similar policy","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"V. PLEASE GIVE ALL OTHER INFORMATION RELEVANT TO THIS CLAIM","fields":[{"help":"Provide any other relevant information about the claim","type":"text","label":"Use additional sheets if space provided is insufficient","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"Clinical Trials and/or Human Volunteers Studies Insurance Policy claims","attachments":[],"declarations":["The insured warrants the truth and completeness of the statements made in the form.","If any false or fraudulent statement is made or relevant facts are concealed, the claim shall be forfeited and the policy void."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customercare@rahejaqbe.com","label":"Claims service mail ID","level":null,"hours":"Monday to Saturday, 9 am to 8 pm","applies_to":"all","source_url":"https://rahejaqbe.com/claims","quote":"Commercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolicy\nServicing\nLet us call you","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"info@mediassistindia.com","label":"Medi Assist TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.c","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashless@mediassist.in","label":"Medi Assist TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":", kindly visit\nhttps://www.medibuddy.in/claim\nToll Free Number :\n1800-4259-449\nEmail Address :\ninfo@mediassistindia.com\ncashless@mediassist.in\nCashless everywhere\nReimbursement claim registration :\nRetail\nCorp employee\nMedi Assist Insurance TPA Pvt. Ltd.\n4th Flo","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"contact.phs@paramounttpa.com","label":"Paramount TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"nonetwork.phs@paramounttpa.com","label":"Paramount TPA Non-network Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ttpa.com/PolicyClaim/PolyClaimStatus.aspx\nToll Free Number :\n9122-66620808\nEmail Address :\ncontact.phs@paramounttpa.com\nnonetwork.phs@paramounttpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nParamount TPA Office","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"assistance@volohealthtpa.com","label":"Volo Health TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ed (Annual Disclosure) – Disclosures Data (22-23)\nTPA Details\nVolo Health\nToll Free Number :\n1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimburse","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashlesseverywhere@volohealthtpa.com","label":"Volo Health TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"losures Data (22-23)\nTPA Details\nVolo Health\nToll Free Number :\n1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"support@volohealthtpa.com","label":"Volo Health TPA Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Surak","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashless@volohealthtpa.com","label":"Volo Health TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nVolo Health Insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customersupport@healthindiatpa.com","label":"HealthIndia Insurance TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Suraksha Bima\n,\nPravasi Bhartiya Bima Yoja","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"preauth@healthindiaindiatpa.com","label":"HealthIndia Insurance TPA Preauth Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"pa.com/CustomerCorner/ClaimStatus.aspx\nToll Free Number :\n1800220102\nEmail Address :\ncustomersupport@healthindiatpa.com\npreauth@healthindiaindiatpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nHealthIndia Insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"help@vidalhealthtpa.com","label":"Vidal Health Insurance TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"o@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Suraksha Bima\n,\nPravasi Bhartiya Bima Yojana\n,\nGroup Hospital Cash\n,","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@rahejaqbe.com","label":"Claims email for two wheeler bundled policy","level":null,"hours":null,"applies_to":"motor","source_url":"https://rahejaqbe.com/uploads/images/tw-bundle/pdf/download/tw-bundle-_Prospectus-V01.pdf","quote":"800-102-7723 or in writing at the nearest Offices or through an intermediary.\n• Alternatively, you can also reach us at claims@rahejaqbe.com You can report with vehicle/ report claim at network garage whereby claim registration shall be done by network garage","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001027723","label":"Claims call centre","level":null,"hours":"Monday to Saturday, 9 am to 8 pm","applies_to":"all","source_url":"https://rahejaqbe.com/claims","quote":"ims!\nExplore\nCommercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-4259-449","label":"Medi Assist TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"p Up\n,\nArogya Sanjeevani\n,\nGroup Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"9122-66620808","label":"Paramount TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"njeevani\n,\nGroup Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800202022","label":"Volo Health TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsuppor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800220102","label":"HealthIndia Insurance TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealtht","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"080-28004114/18004257878","label":"Vidal Health Insurance TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@he","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-102-7723","label":"Call centre for claims intimation","level":null,"hours":"9 am to 8 pm, Monday to Saturday","applies_to":"all","source_url":"https://rahejaqbe.com/uploads/images/two-wheeler-package/pdf/download/tw-package-prospectus-V01.pdf","quote":"ct numbers specified in the Schedule to the Policy.\n• Intimation of claim can also be made to Raheja QBE Call centre at 1800-102-7723 or in writing at the nearest Offices or through the intermediary.\n• Alternatively, you can also reach us at customercar","fetched_at":"2026-10-20"}],"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/raheja-qbe-general-insurance/1040-clinical-trials-and-or-human-volunteers-studies-insurance-policy-claim-form"}