{"id":1220,"title":"Claim Form – Shri Micro Individual Personal Accident Insurance","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/Shri_Micro_IPA_Claim_Form.pdf","sha256":"8e45a24baddf51d12fc6522c32b93f5fbee03b6158e551ad8d159175b559854c","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for filing a personal accident insurance claim under the Shri Micro Individual Personal Accident Insurance policy. It is filled by the insured person or claimant and includes a section for the attending physician.","notes":["The issue of this form is not an admission of liability.","All columns must be filled and no column left unanswered.","Attach separate sheet if space is insufficient.","No claim will be admitted without a Medical Report as per format obtained at claimant's expense.","Please mention N/A wherever not applicable."],"title":"Claim Form – Shri Micro Individual Personal Accident Insurance","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured’s 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 policyholder","type":"text","label":"Name of policy holder","options":[],"required":null,"pdf_field":""},{"help":"Address of the policyholder","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide landline and mobile numbers","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Landline number","type":"phone","label":"Landline:-","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Mobile:-","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Details of the Insured person in respect of whom the claim is made","fields":[{"help":"Name of the insured person for whom claim is made","type":"text","label":"2.1. Name of insured person:","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured person","type":"text","label":"2.2. Address:","options":[],"required":null,"pdf_field":""},{"help":"Contact number of the insured person","type":"phone","label":"2.3. Contact Number:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"In case death of insured person details of nominee","fields":[{"help":"Name of the insured person","type":"text","label":"3.1. Name of insured person:","options":[],"required":null,"pdf_field":""},{"help":"Name of the nominee","type":"text","label":"3.2. Name of Nominee:","options":[],"required":null,"pdf_field":""},{"help":"Relationship of nominee to insured person","type":"text","label":"3.3. Relationship of nominee with insured person:","options":[],"required":null,"pdf_field":""},{"help":"Address of the nominee","type":"text","label":"3.4. Address:","options":[],"required":null,"pdf_field":""},{"help":"Contact number of the nominee","type":"phone","label":"3.5. Contact Number:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Details of Accident","fields":[{"help":"Date when the accident occurred","type":"date","label":"4.1. Date of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Time when the accident occurred","type":"text","label":"4.2. Time of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Location of the accident","type":"text","label":"4.3. Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Brief description of the accident","type":"text","label":"4.4. Please provide brief detail of accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Hospital Details","fields":[{"help":"Hospital or nursing home details","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":"Indicate if police were informed","type":"yes-no","label":"6. Have the police been informed about the accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if injured was under influence","type":"yes-no","label":"7. Was the injured person under the influence of liquor/drugs at time of accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"FIR number if police informed","type":"text","label":"If yes, please give details: FIR No.","options":[],"required":null,"pdf_field":""},{"help":"Police station name where FIR was registered","type":"text","label":"Name of Police Station","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Witness and Contact Details","fields":[{"help":"Indicate if there was a witness","type":"yes-no","label":"8. Witness of accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of witness","type":"text","label":"8.1.","options":[],"required":null,"pdf_field":""},{"help":"Contact details of witness including phone number","type":"text","label":"8.2.","options":[],"required":null,"pdf_field":""},{"help":"Contact details of injured person","type":"text","label":"9. Where the Injured person can be contacted","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Claim Details Section-wise","fields":[{"help":"Fill claim details for each section: Sum Insured, Disability %, Claim Amount. Sections: Accidental Death & Disappearance, Transportation of Mortal Remains, Children’s Education Benefit, Permanent Total Disability, Permanent Partial Disability, Temporary Total Disability, Hospital Confinement Allowance, Accidental Hospitalisation Cover, Medical Expenses Reimbursement, Modification of Accommodation & vehicle, Terrorism. Mention N/A if not applicable.","type":"table","label":"Section","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":"Signature of claimant or insured person","type":"signature","label":"Signature of Claimant / Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant / insured"},{"title":"Attending Physician's Statement","fields":[{"help":"Name of injured person","type":"text","label":"1. Name of Injured Person","options":[],"required":null,"pdf_field":""},{"help":"Age of injured person","type":"number","label":"2. Age","options":[],"required":null,"pdf_field":""},{"help":"Address of injured person","type":"text","label":"3. Address","options":[],"required":null,"pdf_field":""},{"help":"Describe accident and injuries","type":"text","label":"4. 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":"5. 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":"Confirm if injuries are only from accident","type":"yes-no","label":"6. 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 any pre-existing condition contributed","type":"yes-no","label":"7. 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 duration","type":"text","label":"8. Was the Claimant hospitalized? If so for what period?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if patient was intoxicated","type":"yes-no","label":"9. 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":"10. 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":"11. 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":"12. 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":"13. Details about disablement due to accident","options":[],"required":null,"pdf_field":""},{"help":"Signature of attending physician","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":"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":"Shri Micro Individual Personal Accident Insurance claims","attachments":["Medical Report as per format to be obtained at claimant's expense"],"declarations":["The claimant warrants the truth of the details to the best of their knowledge and belief.","If any false or fraudulent declarations are made or material facts are concealed, the policy shall be void and all rights to compensation forfeited."],"dropped_labels":0},"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/1220-claim-form-shri-micro-individual-personal-accident-insurance"}