{"id":1100,"title":"Divyanga Suraksha Claim Form","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/2f486c76f7bf40f78c98bc5c78ee7c9a.pdf","sha256":"98a697fcaf1e77472e03e7a1f61e0abf8db77f3cdf83fa5152af45ab49fe39d0","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or hospital to claim insurance benefits for hospitalization and related expenses under the Divyanga Suraksha policy.","notes":["All fields marked with * are mandatory.","Use DDMMYYYY format for dates unless otherwise specified.","Use HH:MM format for time fields.","Attach a cancelled cheque copy for payee bank details.","Fill Part A by the insured and Part B by the hospital as applicable.","If claim is for domiciliary hospitalization, provide details in annexure.","Use block letters and provide complete postal addresses including pin codes.","Enter amounts in rupees without paise values.","Hospital bills and documents must be attached as per checklist.","Declarations must be signed and dated by the insured and hospital where applicable."],"title":"Divyanga Suraksha Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Hospitalization","fields":[{"help":"Enter the full name of the hospital where admitted","type":"text","label":"Name of Hospital where Admitted:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate room category occupied","type":"choice","label":"Room Category occupied:","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the reason for hospitalization","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of Injury / Date Disease first detected /Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter time in HH:MM format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Enter time in HH:MM format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick the cause of injury","type":"choice","label":"If Injury give cause:","options":["Road Traffic Accident","Self inflicted","Substance Abuse / Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR attached:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine used for treatment","type":"text","label":"System of Medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of Claim","fields":[{"help":"Enter amounts in rupees without paise","type":"amount","label":"Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre-hospitalization Expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post-hospitalization Expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health-Check up Cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance Charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees and specify code","type":"amount","label":"Others (code):","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if yes, provide details in annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees","type":"amount","label":"Details of Lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospital Daily Cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Surgical Cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Critical Illness Benefit:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Convalescence:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre/Post hospitalization","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Others:","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted- Check List:","options":["Claim Form Duly signed","Copy of the claim intimation, if any","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","ECG","Doctor's request for investigation","Investigation Reports (Including CT/ MRI / USG / HPE)","Doctor's Prescriptions","Others"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of Bills Enclosed","fields":[{"help":"Fill columns: SI. No, Bill No, Date (DDMMYY), Issued by, Towards, Amount (Rs)","type":"table","label":"Details of bills enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Payee Details","fields":[{"help":"Enter full bank name","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR number","type":"text","label":"MICR No.","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Details in Case of Non Network Hospital","fields":[{"help":"Enter full postal address including city, state, pin code","type":"text","label":"Address of the Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital phone number with STD code","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital registration number with state code","type":"text","label":"Registration No. with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital PAN number","type":"text","label":"Hospital PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient beds:","options":[],"required":null,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital:","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Hospital authorized signatory to sign","type":"signature","label":"Signature of hospital:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"hospitalization and related claims under Divyanga Suraksha insurance policy","attachments":["Cancelled cheque copy of payee","Claim Form Duly signed","Copy of the claim intimation, if any","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","ECG","Doctor's request for investigation","Investigation Reports (Including CT/ MRI / USG / HPE)","Doctor's Prescriptions","Others","MLC Report & Police FIR (if applicable)"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent and authorization is given to TPA/insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for the claim are included and no supplementary claim will be made except for pre/post-hospitalization claims.","The hospital declares that the information furnished is true and correct and false statements will forfeit the claim."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customer.care@sbigeneral.in","label":"Motor Claims Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"m\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journeys, always\nDownload SBIG App\nRegister or Tra","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"sbig.health@sbigeneral.in","label":"Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"ailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th Floor, Westport, Pan Card","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcitizen.health@sbigeneral.in","label":"Senior Citizen Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 1111","label":"Motor Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"e Claim\nFAQs\nDownload Claim Form\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journ","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 3366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"e simple click\nCheck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 6366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"heck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"sms","value":"561612","label":"Health Claims SMS 'HEALTHCLAIM'","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"y Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office","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/sbi-general-insurance/1100-divyanga-suraksha-claim-form"}