{"id":1202,"title":"Janta Personal Accident Claim Form","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/Janta-Personal-Accident-Claim-Form.pdf","sha256":"d4a86e7e1dad07b71a6ba063da74b96b5c7e7c84610ae61badc050971ad8405b","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming personal accident insurance benefits under the Janta Personal Accident Insurance (Group) policy. It is filled by the insured or claimant and the attending physician.","notes":["The issue of this form is not an admission of liability.","All columns must be filled; no column should remain unanswered.","No claim will be admitted without a Medical Report as per format obtained at claimant's expense.","Attach separate sheet if space is insufficient.","Attach proof/documents for any add-on riders loss claimed.","Attach a copy of the police report if complaint lodged.","Attach postmortem report or death certificate if applicable."],"title":"Janta Personal Accident Claim Form","submit":{"to":"Shriram General Insurance Company Ltd. Head Office","how":"","address":"E-8, EPIP, RIICO Industrial Area, Jaipur-302022"},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance:","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"Insured:","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"Contact Number: Landline:-","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail:","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under the policy","type":"amount","label":"Sum insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Personal Detail","fields":[{"help":"Full name of the claimant","type":"text","label":"Name of claimant","options":[],"required":null,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Claimant's occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Age of the claimant","type":"number","label":"Age","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Accident","fields":[{"help":"Date and time of the accident","type":"date","label":"Time and Date","options":[],"required":null,"pdf_field":""},{"help":"Where the accident occurred","type":"text","label":"Place and Location","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause of the accident","type":"text","label":"Cause (Description)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Injuries","fields":[{"help":"List the injured body parts","type":"text","label":"Specify Injured Part(s) of Body","options":[],"required":null,"pdf_field":""},{"help":"Describe any permanent or total disablement","type":"text","label":"Permanent / Total Disablement if any","options":[],"required":null,"pdf_field":""},{"help":"Percentage of disablement in words and numbers","type":"text","label":"Percentage (In Words) (%)","options":[],"required":null,"pdf_field":""},{"help":"Details of loss on add-on riders with proof","type":"text","label":"Loss on any “Add on” riders  (please attach proof / documents)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Witnesses","fields":[{"help":"Name of witness","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Police Report","fields":[{"help":"Indicate if police complaint was filed","type":"yes-no","label":"Has a complaint been lodged with the Police station?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of police complaint and attach report","type":"text","label":"If Yes, by whom, when & at which Police station? (Attach a copy of the police report).","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Others","fields":[{"help":"Enter confinement start and end dates","type":"date","label":"Total Confinement (This should be the actual days when fully confined to bed on Medical Advice) From To","options":[],"required":null,"pdf_field":""},{"help":"Indicate if past claims were made and provide details","type":"yes-no","label":"Have you made any claims in the PAST? If YES, please give details including accident and Insurance details Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if insured under other policies and provide details","type":"yes-no","label":"Are you insured under any other policy? If YES, please give full details Yes/No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration 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":"Signature of claimant or insured","type":"signature","label":"Signature of the Insured/Claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Attending Physician's Statement","fields":[{"help":"Name of the injured person","type":"text","label":"Name of Injured Person","options":[],"required":null,"pdf_field":""},{"help":"Age of injured person","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Address of injured person","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Describe accident nature and injuries","type":"text","label":"Nature of the Accident and Details of Injuries Sustained","options":[],"required":null,"pdf_field":""},{"help":"Confirm if claimant's cause matches injuries","type":"yes-no","label":"Does the Cause of Accident as stated by the Claimant tally with the Injuries noticed by you?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if injuries are solely due to accident","type":"yes-no","label":"Are the injuries solely due to the accident or traceable to any previous injuries/ disease/ infirmities?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if pre-existing conditions contributed","type":"yes-no","label":"Was the injured person suffering from any disease or injury which may have contributed to the accident or likely to aggravate his condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospitalization details and period","type":"text","label":"Was the Claimant hospitalized? If so for what period?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if claimant was intoxicated","type":"yes-no","label":"Was he under the influence of intoxicants or drugs at the time of accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of prior treatment if any","type":"text","label":"Are you his usual medical Attendant? If you have treated him for any previous illness or injury, please give details","options":[],"required":null,"pdf_field":""},{"help":"Details of other doctors consulted","type":"text","label":"Have other Doctors been in Attendance or Consultation? If yes, Please give details","options":[],"required":null,"pdf_field":""},{"help":"Police case number if reported","type":"text","label":"Has this accident been reported to the Police Authorities? If yes, Case No:","options":[],"required":null,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Police Station :","options":[],"required":null,"pdf_field":""},{"help":"Details of disablement and expenses","type":"text","label":"Details about disablement due to accident including medical expenses","options":[],"required":null,"pdf_field":""},{"help":"Signature of attending physician","type":"signature","label":"Doctor's Signature:","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Reg. No:","options":[],"required":null,"pdf_field":""},{"help":"Name of the doctor","type":"text","label":"Doctors Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of physician's statement","type":"date","label":"Date :","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address and phone number","type":"text","label":"Address and Phone No:","options":[],"required":null,"pdf_field":""}],"filled_by":"attending physician"}],"deadlines":[],"applies_to":"Janta Personal Accident Insurance (Group) claims","attachments":["Medical Report as per format","Separate sheet if space is insufficient","Proof/documents for any Add on riders loss","Copy of police report if complaint lodged","Postmortem report or Death certificate (if applicable)"],"declarations":["The details given are true and correct to the best of the claimant's knowledge.","The claimant authorizes hospital, doctor, laboratory, organization, or any other body to provide information or documents to the Insurance Company."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"chd@shriramgi.com","label":"Help Desk Email ID for claim intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ase download the CLAIM INTIMATION SHEET, fill it and send it to our Help\n                            Desk via Email ID (chd@shriramgi.com)\nNote:\nPlease ensure that the following information is ready with you at the time of\n                            claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-300-30000","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 4:00 AM to Midnight 12:00","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"Option 1:\nIntimate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-3009","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 9:30 am to 5:30 pm","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our Help","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/shriram-general-insurance/1202-janta-personal-accident-claim-form"}