{"id":1218,"title":"Optional Travel Insurance For E-Ticket Passengers of IRCTC - Claims Form","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/Optional-Travel-Insurance-For-ETicket-Passengers-of-IRCTC-Claims-Form.pdf","sha256":"45d286d72a7138a33c80415c994e5c6f4ce98e43435b5ed5b171565927bf11d6","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming insurance benefits under the Optional Travel Insurance for E-Ticket Passengers of IRCTC. It is filled by the insured or claimant and the attending physician.","notes":["All columns of the claim form must be filled by the insured; no column should remain unanswered.","No claim will be admitted without a Medical Report as per format to be obtained at claimant's expense.","Attach a separate sheet if space is insufficient."],"title":"Optional Travel Insurance For E-Ticket Passengers of IRCTC - Claims Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Personal Details and Accident Information","fields":[{"help":"","type":"text","label":"SGI Certificate Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PNR 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":"Full postal address","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 amount","type":"amount","label":"Sum insured","options":[],"required":null,"pdf_field":""},{"help":"Name of the person claiming","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":"Claimant's age","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Time and date of accident","type":"date","label":"Time and Date","options":[],"required":null,"pdf_field":""},{"help":"Place and location of accident","type":"text","label":"Place and Location","options":[],"required":null,"pdf_field":""},{"help":"Description of cause of accident","type":"text","label":"Cause (Description)","options":[],"required":null,"pdf_field":""},{"help":"Specify injured body parts","type":"text","label":"Specify Injured Part(s) of Body","options":[],"required":null,"pdf_field":""},{"help":"Describe total disablement if applicable","type":"text","label":"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":""}],"filled_by":"insured/claimant"},{"title":"Witnesses and Police Report","fields":[{"help":"Names and details of witnesses","type":"text","label":"WITNESSES:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if complaint lodged","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 copy of police 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":"Other Details","fields":[{"help":"Enter confinement period dates","type":"text","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 made and provide details if yes","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 if yes","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":"Sign here","type":"signature","label":"Signature of the Insured/Claimant","options":[],"required":true,"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":true,"pdf_field":""},{"help":"Age of injured person","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Address of injured person","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Describe accident and injuries","type":"text","label":"Nature of the Accident and Details of Injuries Sustained","options":[],"required":true,"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":true,"pdf_field":""},{"help":"Explain if injuries are solely due to accident or pre-existing","type":"text","label":"Are the injuries solely due to the accident or traceable to any previous injuries/ disease/ infirmities?","options":[],"required":true,"pdf_field":""},{"help":"Provide details of any contributing disease or injury","type":"text","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":[],"required":true,"pdf_field":""},{"help":"Hospitalization details and period","type":"text","label":"Was the Claimant hospitalized? If so for what period?","options":[],"required":true,"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":true,"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":true,"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":true,"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":true,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Police Station :","options":[],"required":true,"pdf_field":""},{"help":"Describe disablement details","type":"text","label":"Details about disablement due to accident","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Doctor's Signature:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Reg. No:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Doctors Name:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address and phone number","type":"text","label":"Address and Phone No:","options":[],"required":true,"pdf_field":""}],"filled_by":"attending physician"}],"deadlines":[],"applies_to":"Optional Travel Insurance For E-Ticket Passengers of IRCTC","attachments":["Medical Report as per format","Separate sheet if space is insufficient","Copy of the police report"],"declarations":["The undersigned confirms that the details given are true and correct to the best of their knowledge.","The undersigned authorizes hospital, doctor, laboratory, organization, establishment or any other body or person involved in the claim to provide any information or documents sought by 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/1218-optional-travel-insurance-for-e-ticket-passengers-of-irctc-claims-form"}