{"id":1054,"title":"Motor Insurance - Claim Form","purpose":"claim","insurer":{"slug":"raheja-qbe-general-insurance","name":"Raheja QBE General Insurance Co. Ltd."},"source_pdf":"https://rahejaqbe.com/uploads/images/motor-others/pdf/download/cpa-claim-form-V01.pdf","sha256":"52ebacd5f64f6fbabbf7bc9d325bc382518f2c72f4d5950ca3016dfedab5c463","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured or claimant to report and claim compensation for a motor insurance accident involving the vehicle. The policyholder or claimant fills it.","notes":["Fill the form in Block Letters and tick the boxes where appropriate.","Do not leave any column unanswered; if details are unavailable, they may be sent later.","Please make a sketch on the back of the form to describe how the accident occurred.","Enclose legible copies of required documents duly attested by the insured.","For commercial vehicles, submit additional documents as listed.","Attach a cancelled cheque leaf along with the claim form for direct fund transfer.","Original documents may be required for verification as specified in the document list."],"title":"Motor Insurance - Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Vehicle Details","fields":[{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Vehicle Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Chassis Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Engine Number:","options":[],"required":null,"pdf_field":""},{"help":"Tick the applicable vehicle class","type":"choice","label":"Class of Vehicle (Private/Commercial/Two wheeler):","options":["Private","Commercial","Two wheeler"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Insured/Claimant Details","fields":[{"help":"","type":"text","label":"Insured/Claimant Name","options":[],"required":null,"pdf_field":""},{"help":"Include city, pin code, and state","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":"State","options":[],"required":null,"pdf_field":""},{"help":"Include Mobile No., Office (STD code), Residence (STD code)","type":"text","label":"Contact Nos.","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Office (STD code)","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Residence (STD code)","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Accident Details","fields":[{"help":"Date of accident","type":"date","label":"Accident occurred on","options":[],"required":null,"pdf_field":""},{"help":"Time of accident","type":"text","label":"at Hrs.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe how the accident happened","type":"text","label":"Short Description of Accident","options":[],"required":null,"pdf_field":""},{"help":"Draw a sketch on the back of the form","type":"attachment","label":"Please make a sketch overleaf to describe how accident occurred","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Driver Details","fields":[{"help":"Driver's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Tick the applicable gender","type":"choice","label":"Sex:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Driver's occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving License No.","options":[],"required":null,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Valid up to","options":[],"required":null,"pdf_field":""},{"help":"Specify vehicle types authorized","type":"text","label":"Authorized to drive","options":[],"required":null,"pdf_field":""},{"help":"Authority that issued the license","type":"text","label":"Issuing Authority","options":[],"required":null,"pdf_field":""},{"help":"Driver's mobile number","type":"phone","label":"Mobile No. :","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"text","label":"Badge No","options":[],"required":null,"pdf_field":""},{"help":"Tick the applicable option","type":"choice","label":"Is Driver:","options":["Owner","Paid Driver","Relative / Friend"],"required":null,"pdf_field":""},{"help":"Number of people in the vehicle","type":"number","label":"No of Occupants:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Injury and Police Report","fields":[{"help":"Tick yes if police report was filed","type":"yes-no","label":"Police Report lodged","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"If yes FIR No.","options":[],"required":null,"pdf_field":""},{"help":"Police Station name","type":"text","label":"P.S.","options":[],"required":null,"pdf_field":""},{"help":"Tick yes if any death or injury occurred","type":"yes-no","label":"Death / Injury to any occupant / Third Party (others)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick yes if third party property was damaged","type":"yes-no","label":"Third Party Property Damage","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach extra sheets if needed","type":"attachment","label":"Attach additional details in case of death and/or injury to Third Party / Occupants / Driver or damage to property.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Additional Details for Commercial Vehicles","fields":[{"help":"Permit number for commercial vehicle","type":"text","label":"Permit No.","options":[],"required":null,"pdf_field":""},{"help":"Permit expiry date","type":"date","label":"Valid upto","options":[],"required":null,"pdf_field":""},{"help":"Fitness certificate expiry date","type":"date","label":"Fitness Valid upto","options":[],"required":null,"pdf_field":""},{"help":"LR/GR number","type":"text","label":"LR/GR No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Number of Passengers carried","options":[],"required":null,"pdf_field":""},{"help":"Describe goods carried","type":"text","label":"Nature of Goods carried","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Other Insurance","fields":[{"help":"Provide details or attach separate sheet if needed","type":"text","label":"Details of other insurance Policies indemnifying the Insured in respect of this accident :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Bank Details for Claim Payment","fields":[{"help":"","type":"text","label":"Bank Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Name & Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code:","options":[],"required":null,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR code","options":[],"required":null,"pdf_field":""},{"help":"Account number to receive claim payment","type":"text","label":"Payee Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Name of account holder","type":"text","label":"Name of Payee:","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"text","label":"UPI address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declarations and Signature","fields":[{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":[],"applies_to":"","attachments":["Registration Certificate","Driving License (of the driver)","FIR if lodged","Fire Brigade Report if lodged","Permit (for commercial vehicles)","Fitness Certificate (for commercial vehicles)","LR / GR (for commercial vehicles)","Cancelled Cheque leaf for Direct Fund Transfer/EFT Mandate Form"],"declarations":["I/We agree to provide additional information to the Company if required.","I/We warrant the truth of the foregoing statement and understand that false declaration or suppression of material information will void the policy and forfeit claim rights.","I/We consent to the Company collecting, retaining, and sharing my/our personal and sensitive information for policy servicing and claim settlement.","I/We understand that I/We can update or withdraw consent for information sharing, but withdrawal may affect services provided."],"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/1054-motor-insurance-claim-form"}