{"id":1260,"title":"Retail Personal Accident Claim Form","purpose":"claim","insurer":{"slug":"tata-aig-general-insurance","name":"Tata AIG General Insurance Company Limited"},"source_pdf":"https://www.tataaig.com/s3/retail_personal_accident_df914eb28e.pdf","sha256":"5a60c04f561c5653d18ee18342cab0df203a1b841184a48b242234b482bfd14c","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim benefits under a retail personal accident insurance policy. It collects details about the accident, treatment, and claim amounts.","notes":["Please be available at the contact address and phone for the insurance representative.","The confinement dates should reflect actual days fully or partially confined to bed on medical advice.","The Attending Physician's Statement must be fully completed by the treating doctor."],"title":"Retail Personal Accident Claim Form","submit":{"to":"A&H Claims Department, Tata AIG General Insurance Co. Ltd., 7 and 8 Floor, Romell Tech Park, Cama Industrial Estate, Western Express Highway, Goregaon(E), Mumbai, Maharashtra 400063","how":"post","address":"A&H Claims Department, Tata AIG General Insurance Co. Ltd., 7 and 8 Floor, Romell Tech Park, Cama Industrial Estate, Western Express Highway, Goregaon(E), Mumbai, Maharashtra 400063"},"purpose":"claim","sections":[{"title":"Treatment Details","fields":[{"help":"","type":"text","label":"Name of Casualty Doctor","options":[],"required":null,"pdf_field":""},{"help":"Address of the casualty doctor","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the casualty doctor","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Medical registration number of the casualty doctor","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Family Doctor","options":[],"required":null,"pdf_field":""},{"help":"Address of the family doctor","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the family doctor","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Medical registration number of the family doctor","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Contact Details","fields":[{"help":"Address where the insured can be contacted","type":"text","label":"Address where available","options":[],"required":null,"pdf_field":""},{"help":"Phone number where the insured can be contacted","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Amount of Claim","fields":[{"help":"Enter amount claimed for temporary disablement","type":"amount","label":"Total Temporary Disablement Amount (Rs)","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed for permanent disablement","type":"amount","label":"Permanent Disablement Amount (Rs)","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed for medical expenses","type":"amount","label":"Medical Expenses Amount (Rs)","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed for death benefit","type":"amount","label":"Death Amount (Rs)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Past History","fields":[{"help":"Indicate if you have made any previous claims","type":"yes-no","label":"Have you made any claims in the PAST ?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide details of past claims if any","type":"text","label":"If YES, please give details including accident and Insurance details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Indicate if you have other insurance policies","type":"yes-no","label":"Are you insured under any other policy ?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies","type":"text","label":"If YES, please give full details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Police Information","fields":[{"help":"Indicate if police were informed","type":"yes-no","label":"Have the Police Authorities been informed of this accident?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Police case number if applicable","type":"text","label":"If YES, Case No.","options":[],"required":null,"pdf_field":""},{"help":"Name of police station where case was reported","type":"text","label":"Police Station","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"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","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Attending Physician's Statement","fields":[{"help":"","type":"text","label":"Name of Injured Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone","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":"","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":"Explain if injuries relate to previous conditions","type":"text","label":"Are the injuries solely due to the accident or traceable to any previous injuries/ disease/ infirmities?","options":[],"required":null,"pdf_field":""},{"help":"","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":null,"pdf_field":""},{"help":"Specify hospitalization details","type":"text","label":"Was the Claimant hospitalized? If so for what period?","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment and operations","type":"text","label":"What treatment was given and Operations performed?","options":[],"required":null,"pdf_field":""},{"help":"Enter treatment period at clinic/hospital","type":"date","label":"Give all dates of treatment : Clinic/Hospital: From To","options":[],"required":null,"pdf_field":""},{"help":"Enter treatment period at home","type":"date","label":"Home : From To","options":[],"required":null,"pdf_field":""},{"help":"","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":"","type":"yes-no","label":"Are you his usual medical Attendant?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide details of previous treatments if any","type":"text","label":"If you have treated him for any previous illness or injury, please give details.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have other Doctors been in Attendance or Consultation?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Details of other doctors consulted","type":"text","label":"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":"","type":"yes-no","label":"Is this claimant Totally Disabled from each and every occupation?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Period of total disability","type":"date","label":"(a) How long was or will the claimant be totally disabled from current occupation? From To","options":[],"required":null,"pdf_field":""},{"help":"Period of partial disability","type":"date","label":"(b) How long was or will the claimant be partially disabled from current occupation? From To","options":[],"required":null,"pdf_field":""},{"help":"Expected return to work date","type":"date","label":"(c) Estimated date of return to Work.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's prognosis","type":"text","label":"What is the Prognosis?","options":[],"required":null,"pdf_field":""},{"help":"Doctor to sign here","type":"signature","label":"Doctor's Signature","options":[],"required":null,"pdf_field":""},{"help":"Date of doctor's signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Regn No","options":[],"required":null,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Doctors Name","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address and phone number","type":"text","label":"Address and Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""}],"filled_by":"attending doctor"}],"deadlines":[],"applies_to":"retail personal accident insurance claims","attachments":[],"declarations":["I declare that I have suffered injuries as described and all details are true and correct.","I agree to forfeit rights to compensation if any facts are false or incorrect.","I authorize hospital, doctor, laboratory or any other body involved to provide information or documents to the Insurance Company."],"dropped_labels":2},"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/1260-retail-personal-accident-claim-form"}