{"id":1257,"title":"PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) CLAIM-CUM-DISCHARGE FORM","purpose":"claim","insurer":{"slug":"tata-aig-general-insurance","name":"Tata AIG General Insurance Company Limited"},"source_pdf":"https://www.tataaig.com/s3/PMSBY_Claim_Form_64f054dc1e.pdf","sha256":"aff0e1c8eab45cf43cc7be138e3bd2c8feeb18ce473115047cbe2ca4f33a34f6","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for claiming insurance benefits under the Pradhan Mantri Suraksha Bima Yojana (PMSBY) by the insured member in case of accidental disability or by the nominee/legal heir in case of death of the insured member.","notes":["The appointee is the person named by the member in his PMSBY enrolment form where the nominee is a minor.","A claimant where there is no nomination or the nominee has pre-deceased the insured member shall be one who is a legal heir and submits a succession certificate or legal heir certificate issued by a competent court or authority.","Accident means a sudden, unforeseen and involuntary event caused by external, violent and visible means.","Permanent Disability means total and irrecoverable loss of both eyes or loss of use of both hands or feet or loss of sight of one eye and loss of use of one hand or foot (total disability) or total and irrecoverable loss of sight of one eye or loss of use of one hand or foot (partial disability).","Documents in support of proof of permanent disability include FIR or Panchnama, disability certificate issued by the Civil surgeon, and hospital record supporting the same.","Documents in support of death due to accident include death certificate, hospital discharge summary, certificate by last attending registered medical practitioner countersigned by a gazetted officer or bank/public sector insurer officer, FIR/Panchnama, post mortem report, or certificate issued by District Magistrate or authorized Executive Magistrate.","In case of death due to accidents such as snake bite or fall from tree, hospital record specifying details may be submitted in lieu of other documents.","Aadhaar number and PAN are desirable but not mandatory.","KYC documents acceptable include Aadhaar card, electoral photo identity card (EPIC), MGNREGA card, driving license, PAN card, or passport."],"title":"PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) CLAIM-CUM-DISCHARGE FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part 1. Details of the member enrolled under PMSBY","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Account number where claim amount will be credited","type":"text","label":"Bank / post office account number:","options":[],"required":null,"pdf_field":""},{"help":"Specify exact day, date and time of accident","type":"date","label":"Day, date, and time of accident:","options":[],"required":null,"pdf_field":""},{"help":"Location where accident occurred","type":"text","label":"Place of occurrence:","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident briefly","type":"text","label":"Nature of accident:","options":[],"required":null,"pdf_field":""},{"help":"If applicable, date of death of insured member","type":"date","label":"Date of death:","options":[],"required":null,"pdf_field":""},{"help":"Describe the disability caused by accident","type":"text","label":"Details of disability:","options":[],"required":null,"pdf_field":""},{"help":"Attach relevant proof documents","type":"attachment","label":"Document attached as proof of permanent disability / death:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured member or nominee/legal heir"},{"title":"Part 2. Details of the nominee in case of death of insured member","fields":[{"help":"","type":"text","label":"Name of the nominee:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age of nominee:","options":[],"required":null,"pdf_field":""},{"help":"Name of person appointed to act for minor nominee","type":"text","label":"In case the nominee is a minor, name of the appointee:","options":[],"required":null,"pdf_field":""},{"help":"Name of legal heir claimant if no nominee or nominee pre-deceased","type":"text","label":"In case of no nomination or nominee pre-deceasing the insured member, name of the claimant:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship of the nominee/claimant with the deceased:","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of nominee/appointee/claimant","type":"phone","label":"Contact mobile number:","options":[],"required":null,"pdf_field":""},{"help":"Email address of nominee/appointee/claimant","type":"email","label":"Contact email address:","options":[],"required":null,"pdf_field":""},{"help":"Address of nominee/appointee/claimant","type":"text","label":"Contact address:","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Details of the nominee/appointee/claimant (as the case may be): Particulars of bank account into which the claim amount is to be remitted: Account number:","options":[],"required":null,"pdf_field":""},{"help":"Bank name of account for claim payment","type":"text","label":"Name of bank:","options":[],"required":null,"pdf_field":""},{"help":"Bank branch IFSC code","type":"text","label":"Branch IFS Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"nominee or appointee or claimant/legal heir"},{"title":"Declaration and signature","fields":[{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the insured member/ nominee/ appointee/ claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"insured member/nominee/appointee/claimant"},{"title":"Part 3: Details in respect of the insured member (to be filled by bank/post office)","fields":[{"help":"","type":"text","label":"Bank / post office account number (as per bank’s CBS/ post office records):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank / post office name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch IFS Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of father/husband of the member:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of birth (as per the KYC document):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the insurer:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the nominee:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of debit of premium from the bank/ post office account:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of remitting the premium into insurer’s account:","options":[],"required":null,"pdf_field":""}],"filled_by":"bank or post office official"},{"title":"Certification by bank/post office official","fields":[{"help":"Place of certification","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Date of certification","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Signature and seal here","type":"signature","label":"Signature and seal of the authorised official of the bank/post office","options":[],"required":null,"pdf_field":""}],"filled_by":"bank or post office official"},{"title":"Advance receipt for discharge of claim","fields":[{"help":"Witness signature","type":"signature","label":"Signature of the witness","options":[],"required":null,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness:","options":[],"required":null,"pdf_field":""},{"help":"Signature here","type":"signature","label":"Signature of the insured member/nominee/appointee/claimant","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Bank/post office official countersignature","type":"signature","label":"Countersignature of authorised official of the bank/post office","options":[],"required":null,"pdf_field":""},{"help":"Date of countersignature","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Name of bank/post office official","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Bank/post office name","type":"text","label":"Name of bank/post office:","options":[],"required":null,"pdf_field":""},{"help":"Branch name","type":"text","label":"Branch:","options":[],"required":null,"pdf_field":""},{"help":"Stamp of bank/post office","type":"attachment","label":"Office stamp","options":[],"required":null,"pdf_field":""}],"filled_by":"insured member/nominee/appointee/claimant and bank/post office official"}],"deadlines":["To be submitted preferably within 30 days of the occurrence of the accident of the insured member giving rise to the claim"],"applies_to":"claims under Pradhan Mantri Suraksha Bima Yojana (PMSBY) for accidental disability or death","attachments":["Proof of permanent disability due to accident or death due to accident of the insured member","Aadhaar and PAN number of the insured member and claimant (Optional)","KYC document in respect of the nominee/appointee/claimant","First two pages of passbook, or bank/post office account statement showing account details, or cancelled cheque of the account of the nominee/appointee/claimant","Proof of death of nominee in case of nominee pre-deceasing the insured member","Proof of being legal heir, in case the claimant is other than the insured member/nominee/appointee","Advance receipt for discharge of claim, duly filled in and signed"],"declarations":["I hereby declare that details submitted above are true to the best of my knowledge.","The documents attached in support of this claim are genuine.","I have not claimed the amount payable under PMSBY in respect of the member named above earlier or in respect of any other account of the member with any bank or post office.","It is certified by the bank/post office official that the information is true as per PMSBY enrolment data and bank/post office records.","In consideration of approval of my claim, I accept the sum from Tata AIG General Insurance Company Limited in full and final settlement and discharge of my claim under the policy."],"dropped_labels":10},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana","label":"Claims Submission Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_cis_e7df7ce2ec.pdf","quote":"tion or procedure. Submit claim documents within 15 days of occurrence of incident. Kindly send the claim documents to: TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1- 6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone-040-66864900 Assistance: 1. Website www.tataaig.com or Call 24*7 Customer Support No.: 022 6489 8282/1800 267 1","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"healthclaimsupport@tataaig.com","label":"Health Claims Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_prospectus_efd23b0ad6.pdf","quote":"al Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900\nEmail ID | healthclaimsupport@tataaig.com\nCustomer Support Number: | 022 6489 8282 / 1800 267 1955 (nly for senior citizen policy holders)\nWebsite | www.tataaig.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"040-66864900","label":"Claims Administrator Phone","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_prospectus_efd23b0ad6.pdf","quote":"th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900\nEmail ID | healthclaimsupport@tataaig.com\nCustomer Support Number: | 022 6489 8282 / 1800 267 1955 (nly for senior citi","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/tata-aig-general-insurance/1257-pradhan-mantri-suraksha-bima-yojana-pmsby-claim-cum-discharge-form"}