{"id":1094,"title":"PERSONAL ACCIDENT DISABLEMENT CLAIM FORM","purpose":"claim","insurer":{"slug":"royal-sundaram-general-insurance","name":"Royal Sundaram General Insurance Company Limited"},"source_pdf":"https://www.royalsundaram.in/assets/claim-forms/personal-accident-insurance/PerAccDisabl.pdf","sha256":"b5abbc912a9f72143562e91955e00f9e241201ad2eb5bd775c19c3d721b3a480","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person or claimant to claim compensation for personal accident disablement under the insurance policy.","notes":["All questions must be answered in capital letters using an ink pen.","Strike out inapplicable options in the eye witness certificate.","Ensure the form is fully completed, signed, and dated before submission."],"title":"PERSONAL ACCIDENT DISABLEMENT CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured/Insured Person Details","fields":[{"help":"Write the full name in capital letters","type":"text","label":"Name of the Insured/Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Write the full name in capital letters","type":"text","label":"Name of the injured Person","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address for Correspondence","options":[],"required":true,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"As per insurance policy document","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"If applicable","type":"text","label":"Card Number / Account Number","options":[],"required":false,"pdf_field":""},{"help":"Bank for claim payment","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Telephone Daytime / Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Telephone Evening","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Details of the Accident","fields":[{"help":"Date when the accident occurred","type":"date","label":"Date of the accident (DD/MM/YY)","options":[],"required":true,"pdf_field":""},{"help":"Approximate time of accident","type":"text","label":"Time of accident (AM/PM)","options":["AM","PM"],"required":true,"pdf_field":""},{"help":"Location where accident happened","type":"text","label":"Place of accident","options":[],"required":true,"pdf_field":""},{"help":"Describe how the accident happened","type":"text","label":"Nature and cause of accident","options":[],"required":true,"pdf_field":""},{"help":"Indicate if police were informed","type":"yes-no","label":"Was the accident reported to the Police?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name and address of police station","type":"text","label":"If Yes please give the address of the Police Station","options":[],"required":false,"pdf_field":""},{"help":"Explain why police were not informed","type":"text","label":"If No please give reason why","options":[],"required":false,"pdf_field":""},{"help":"FIR number and date if available","type":"text","label":"First Information Report Number & Date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Details of Injury","fields":[{"help":"Describe injury and specify side if applicable","type":"text","label":"Nature of injury/disablement (if limb or eye is injured, please state whether right or left)","options":[],"required":true,"pdf_field":""},{"help":"Full details of doctor treating the injury","type":"text","label":"Name and Address of the attending physician (with Pin Code) & Phone No.","options":[],"required":true,"pdf_field":""},{"help":"Indicate if other personal accident insurance exists","type":"yes-no","label":"Does the injured person have any other Personal Accident insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of other insurer","type":"text","label":"If yes, please give the name and address of the Insurance company","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Declaration","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature / thumb impression of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Certificate from the Eye Witness to the Accident","fields":[{"help":"Name of injured as witnessed","type":"text","label":"Name of the injured person","options":[],"required":true,"pdf_field":""},{"help":"Sign or thumb impression","type":"signature","label":"Signature / thumb impression of the eye witness","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Address of eye witness","type":"text","label":"Address","options":[],"required":true,"pdf_field":""}],"filled_by":"eye witness"},{"title":"Medical Certificate Forming Part of Personal Accident Disablement Claim Form","fields":[{"help":"Patient details","type":"text","label":"Name and Address of the injured person","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age of the injured person","options":[],"required":true,"pdf_field":""},{"help":"Hospital details","type":"text","label":"Name & Address of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Inpatient or outpatient number","type":"text","label":"IP / OP Number","options":[],"required":false,"pdf_field":""},{"help":"Medical description of injury","type":"text","label":"Describe nature and extent of injury","options":[],"required":true,"pdf_field":""},{"help":"Physician's knowledge of accident cause","type":"text","label":"Nature & cause of accident (so far as it is known to you)","options":[],"required":true,"pdf_field":""},{"help":"Is treatment ongoing?","type":"yes-no","label":"Are you still attending on him/her?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Is this the regular doctor?","type":"yes-no","label":"Are you his/her usual Medical attendant?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Previous medical history if any","type":"text","label":"If you have treated him/her for any previous illness or injury, please give details","options":[],"required":false,"pdf_field":""},{"help":"Confirm if injuries are only from accident","type":"yes-no","label":"Are his/her injuries a. Solely due to the accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain other causes","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Medical opinion on cause of disablement","type":"yes-no","label":"Could the injuries, sustained in this accident be the sole cause of disablement","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Period of confinement start and end dates","type":"date","label":"According to you, how long should the injured person be confined to bed / house as the direct and sole consequence of the injury sustained?","options":[],"required":true,"pdf_field":""},{"help":"Can patient work during recovery?","type":"yes-no","label":"During this period will the injured person be able to attend to his/her normal duties?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Expected date to resume duties","type":"date","label":"If not, Please state probable date of his / her being able to attend to his normal duties","options":[],"required":false,"pdf_field":""},{"help":"Current medical condition","type":"text","label":"Present Condition","options":[],"required":true,"pdf_field":""},{"help":"Percentage of partial disablement","type":"number","label":"If yes please specify percentage","options":[],"required":false,"pdf_field":""},{"help":"Additional comments","type":"text","label":"Any other remarks you wish to make","options":[],"required":false,"pdf_field":""},{"help":"Full name of attending doctor","type":"text","label":"Doctor's Name","options":[],"required":true,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Registration No","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Date of certificate","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Doctor's email address","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""}],"filled_by":"attending physician"}],"deadlines":[],"applies_to":"Personal Accident Disablement claims","attachments":["First Information Report - Photocopy duly attested by the issuing authority","Medical certificate forming part of the claim form","Admission / Discharge summary issued by hospital authority","English translation of vernacular documents","Medical bills and cash receipts in original","In case of temporary total disablement, leave certificate from the employer, if in service."],"declarations":["The insured declares that all statements are true and no information is concealed.","False or fraudulent statements will void the policy and forfeit compensation.","The insured agrees to make a statutory declaration if required.","The eye witness certifies presence at the accident and truthfulness of the statement.","The attending physician certifies the injuries and treatment details as true."],"dropped_labels":15},"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/royal-sundaram-general-insurance/1094-personal-accident-disablement-claim-form"}