{"id":1273,"title":"Loss of License Insurance – Claim Form","purpose":"claim","insurer":{"slug":"united-india-insurance","name":"United India Insurance Company Limited"},"source_pdf":"https://uiic.co.in/web/sites/default/files/Policy-Document/Aviation%20-%20Loss%20of%20License%20Policy_0.pdf","sha256":"486978bc4d30b16e41a8fc1c4cf41c87ac730a6d91e6b42000fa25ee293dbab2","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim under the Loss of License Insurance policy by providing details of their illness or injury and related information.","notes":["The issue of this form is not an admission of liability.","Return the form promptly even if some particulars are not immediately available; they may be sent later."],"title":"Loss of License Insurance – Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Particulars of Claim","fields":[{"help":"Enter the claim number if available","type":"text","label":"CLAIM NO……………………………..","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"POLICY NO……………………………………..","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured person","type":"text","label":"1 a) Name of the Insured:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the insured person","type":"text","label":"b) Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"2. Age of the Insured Person:","options":[],"required":null,"pdf_field":""},{"help":"Enter your current occupation or profession","type":"text","label":"3. Occupation/Profession:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy period as per your insurance document","type":"text","label":"4. Policy Period:","options":[],"required":null,"pdf_field":""},{"help":"Describe your illness or injuries in detail","type":"text","label":"5.Please state in full the nature and extent of the illness you suffered/injuries you sustained :","options":[],"required":null,"pdf_field":""},{"help":"Provide name and address of the first medical attendant","type":"text","label":"6. Please give and address of the Medical attendant whom you first consulted for this illness/injuries :","options":[],"required":null,"pdf_field":""},{"help":"Indicate if this is your usual medical attendant","type":"yes-no","label":"a) Is he usual Medical Attendants.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if any other medical practitioner was consulted","type":"yes-no","label":"b) Has any other Medical man been consulted","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide expected date or period of recovery","type":"text","label":"7. If you are still disabled, please indicate when you are likely to be fit to resume your usual business or occupation, either wholly or in part","options":[],"required":null,"pdf_field":""},{"help":"Provide convenient date, time and place for visit","type":"text","label":"8. When and where can you be visited (if necessary) by a Medical Officer or an official of the Company","options":[],"required":null,"pdf_field":""},{"help":"Provide date of last medical attention before current illness/injury","type":"date","label":"9. When did you last receive medical attention previous to this illness/injuries","options":[],"required":null,"pdf_field":""},{"help":"Provide details if insured elsewhere for this insurance","type":"text","label":"10. Are you insured with any other office for this insurance. If so, please furnish the name and address of the office and the policy number.","options":[],"required":null,"pdf_field":""},{"help":"Enter the claim amount","type":"amount","label":"11. What amount do you claim under our policy.","options":[],"required":null,"pdf_field":""},{"help":"Explain calculation or basis of claim amount","type":"text","label":"a) Please give details of how this amount has been arrived at .","options":[],"required":null,"pdf_field":""},{"help":"Provide all requested license details","type":"text","label":"12. State the following : a) No. and type of your Aviation License b) Date of License and by whom granted c) Date of expiry of License d) Date of last medical examination for license","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any restrictions or qualifications on license","type":"text","label":"13. Has any restriction or qualification has been placed on your license for medical or any other reason before this claim. If so, please give details","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of your aircrew association","type":"text","label":"14. Name of the aircrew association of which you are a member","options":[],"required":null,"pdf_field":""},{"help":"Provide details of your annual remuneration including components","type":"text","label":"15. What is your present total annual remuneration from your occupation as a member of aircrew. Please give details i.e Basic Pay, DA etc.","options":[],"required":null,"pdf_field":""},{"help":"Provide full details of the accident as requested","type":"text","label":"16. To be filled in, if the Claim relates to injuries : a) Please state when and where the accident took place. b) Please give date, hour and place. c) If accident occurred in an Aircraft, give type and identification mark thereof. d) Please state how the accident happened, what were you doing at that time. e) Whether you were on board the Aircraft as a member of the crew or a passenger. f) Were you in good health and free from physical defects or infinity at the time of accident. g) If at the time of the accident you were flying as a member of aircrew then state the name of your employer or on behalf of whom you were flying.","options":[],"required":null,"pdf_field":""},{"help":"Provide full details related to illness as requested","type":"text","label":"16. To be filled in, if the Claim relates to illness : a) When did the illness commenced. b) Have you ever suffered before from the complaint in respect of which you are claiming c) Have you ever made any claim for compensation in respect of any illness with this company or with any other company. Please give details d) Are there any unusual circumstances connected with your occupation or mode of life that would render you more than usually susceptible to disclose.","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured Person/Representative","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"Loss of License Insurance claims","attachments":[],"declarations":["The information provided is true and correct to the best of my knowledge and belief."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"mayfair.claims@mayfairwecare.com","label":"Overseas Mediclaim Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Worldwide - Excluding USA & Canada -","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"mayfairassist@mayfairwecare.com","label":"Overseas Mediclaim Medical Emergency Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"://www.mayfairwecare.com/contact/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Wor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18004190133","label":"Overseas Mediclaim Policy Toll-Free Number (India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"l - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact/\nWebsite\nhttps://w","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18888811701","label":"Overseas Mediclaim Policy Toll-Free Number (United States)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"ss\nTower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Loc","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08083045211","label":"Overseas Mediclaim Policy Toll-Free Number (United Kingdom)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"nowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please v","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18885192693","label":"Overseas Mediclaim Policy Toll-Free Number (Canada)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"annerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.may","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8003211710","label":"Overseas Mediclaim Policy Toll-Free Number (Singapore)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"lore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001236889","label":"General Contact Number","level":null,"hours":null,"applies_to":"all","source_url":"https://uiic.co.in/web/","quote":"Links\nCustomer Portal\nKYC Process\nFacebook\nInstagram\nYoutube\nTwitter\nOffice Locator\nIntermediary Portal\nDigi Locker\ntel:18001236889","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/united-india-insurance/1273-loss-of-license-insurance-claim-form"}