{"id":1203,"title":"Shri Group Personal Accident Insurance Co. Ltd. Claim Form","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/Shri-GPA-Claim-Form.pdf","sha256":"3ca0fda684b52b6b4a625e09d6efcbb8b1be88fae3b9d4a77f2f9248ad3e06c6","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for filing a personal accident insurance claim by the insured or claimant to Shriram General Insurance Co. Ltd.","notes":["All columns of the claim form must be filled; no column should remain unanswered.","Attach a medical report as per the specified format at claimant's expense.","Attach a separate sheet if space is insufficient."],"title":"Shri Group Personal Accident Insurance Co. Ltd. Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Claimant 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":"","type":"text","label":"Name of policy holder:","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Provide both landline and mobile numbers if available","type":"phone","label":"Contact Number: Landline:- Mobile:-","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"E-mail:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of the Insured Person","fields":[{"help":"","type":"text","label":"Name of insured person:","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Phone number of insured person","type":"phone","label":"Contact Number:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Nominee Details in Case of Death","fields":[{"help":"","type":"text","label":"Name of insured person:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Nominee:","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship (e.g. spouse, child)","type":"text","label":"Relationship of nominee with insured person:","options":[],"required":null,"pdf_field":""},{"help":"Nominee's full postal address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Nominee's phone number","type":"phone","label":"Contact Number:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Accident Details","fields":[{"help":"Date when accident occurred","type":"date","label":"Date of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Time when accident occurred","type":"text","label":"Time of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Location where accident happened","type":"text","label":"Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe accident circumstances briefly","type":"text","label":"Please provide brief detail of accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Hospital Details","fields":[{"help":"Full name and address of hospital or nursing home","type":"text","label":"Name and Address of Hospital/Nursing home where the injured is treated","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Police Information","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Have the police been informed about the accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide FIR number if police informed","type":"text","label":"If yes, please give details: FIR No.","options":[],"required":null,"pdf_field":""},{"help":"Name of police station where FIR registered","type":"text","label":"Name of Police Station","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Influence of Liquor/Drugs","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Was the injured person under the influence of liquor/drugs at time of accident","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Witness Details","fields":[{"help":"Name and phone number of first witness","type":"text","label":"Witness of accident Name and contact details including Phone number 8.1.","options":[],"required":null,"pdf_field":""},{"help":"Name and phone number of second witness","type":"text","label":"Witness of accident Name and contact details including Phone number 8.2.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Contact Details of Injured Person","fields":[{"help":"Contact address or phone of injured person","type":"text","label":"Where the Injured person can be contacted","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration","fields":[{"help":"Place where form is signed","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant / Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant/insured"},{"title":"Attending Physician's Statement","fields":[{"help":"","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 and injuries","type":"text","label":"Nature of the Accident and Details of Injuries Sustained","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","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":"Answer yes or no","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":"Answer yes or no","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":"Specify hospitalization period if any","type":"text","label":"Was the Claimant hospitalized? If so for what period?","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","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":"Provide details of previous 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":"List other doctors if any","type":"text","label":"Have other Doctors been in Attendance or Consultation? If yes, Please give details","options":[],"required":null,"pdf_field":""},{"help":"Provide 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":"Describe any disablement caused","type":"text","label":"Details about disablement due to accident","options":[],"required":null,"pdf_field":""},{"help":"Doctor to sign here","type":"signature","label":"Doctor's Signature:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Reg. No:","options":[],"required":null,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Doctors Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","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":"Shri Group Personal Accident Insurance claims","attachments":["Medical Report as per format to be obtained at claimant's expense","Separate sheet if space is insufficient"],"declarations":["The claimant warrants the truth of the details to the best of their knowledge.","If any false or fraudulent declaration is made or material fact is concealed, the policy shall be void and all compensation rights forfeited."],"dropped_labels":1},"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/1203-shri-group-personal-accident-insurance-co-ltd-claim-form"}