{"id":1279,"title":"AVIATION PERSONAL ACCIDENT 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-%20Personal%20Accident%20Policy%20for%20Crew%20Members.pdf","sha256":"b1e470867773ce632b012860969be41a09f3d21b76ce17dd0b6351e8b06c29d0","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for crew members insured under the Aviation Personal Accident Policy to claim compensation for injuries sustained in an accident. The claimant (insured crew member) fills the form and the medical attendant completes the medical report.","notes":["This form is issued without admission of liability.","Attach all medical certificates, reports, and discharge summaries with the claim form.","The medical report must be completed by the claimant's medical attendant with full details."],"title":"AVIATION PERSONAL ACCIDENT CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant Details and Accident Information","fields":[{"help":"","type":"text","label":"CLAIM No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"POLICY No","options":[],"required":null,"pdf_field":""},{"help":"Enter your full name as per policy","type":"text","label":"Name in full","options":[],"required":null,"pdf_field":""},{"help":"Enter your current age in years","type":"number","label":"Present Age ___________ Years","options":[],"required":null,"pdf_field":""},{"help":"Enter your residential address","type":"text","label":"Residence","options":[],"required":null,"pdf_field":""},{"help":"Enter your height in feet and inches","type":"text","label":"Height ______ Ft. _____ In","options":[],"required":null,"pdf_field":""},{"help":"Enter your weight in kilograms and grams","type":"text","label":"Weight ____ __ Kg. _____ Grams","options":[],"required":null,"pdf_field":""},{"help":"Enter your business or office address","type":"text","label":"Business Address","options":[],"required":null,"pdf_field":""},{"help":"Enter your occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Provide exact day, date and time of accident","type":"text","label":"(a) When did accident occur? State day, date and hour","options":[],"required":true,"pdf_field":""},{"help":"Provide location of accident","type":"text","label":"(b) Where did occur","options":[],"required":true,"pdf_field":""},{"help":"Describe cause of accident and injuries in detail","type":"text","label":"(c) Give full particulars of the cause and the injuries sustained","options":[],"required":true,"pdf_field":""},{"help":"Provide witness details if any","type":"text","label":"Give name and address of the witness of the accident","options":[],"required":null,"pdf_field":""},{"help":"List all doctors who treated you for the injury","type":"text","label":"(a) Give name and address of the Doctors who attended you","options":[],"required":null,"pdf_field":""},{"help":"Provide details of your regular doctor","type":"text","label":"(b) Name and address of your ordinary Medical Attendant","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital details and attach medical documents","type":"text","label":"(C) Name & Address of Hospital where treatment is taken along with all the Medical Certificates, Reports, Discharge Summary etc.","options":[],"required":null,"pdf_field":""},{"help":"Provide place and time for company officer visit","type":"text","label":"State where and when a Medical or Officer of the company can visit Insured/claimant, if necessary.","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days confined to bed","type":"number","label":"(a) State the number of days you have been necessarily and entirely confined to Bed Room of House as the sole and direct result of the injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"If still confined, state where","type":"text","label":"(b) If still confined to any state which","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you worked during confinement","type":"yes-no","label":"(c) Have you in any way attended to business or work during the above period","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If resumed work, provide date","type":"text","label":"(d) Have you been able to attend to any portion of your business or occupation and if so, from what date","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any previous claims","type":"text","label":"Have you previously claimed or received compensation under an Accident and/or Sickness Policy? If so, please give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you have other insurance","type":"yes-no","label":"(a) Are you insured elsewhere?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide other insurer names and claim amounts","type":"text","label":"(b) If so, give the name of each Company or Insurer and amount you are entitled to claim","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Dated","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Report","fields":[{"help":"","type":"text","label":"CLAIM No","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's full name","type":"text","label":"CLAIMANT Name in Full","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's age","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries and specify limb side if applicable","type":"text","label":"The nature and extent of injuries (Is to a limb state whether right or left)","options":[],"required":true,"pdf_field":""},{"help":"Describe cause of accident from medical perspective","type":"text","label":"The cause of the accident, so far as known to you","options":[],"required":true,"pdf_field":""},{"help":"Date when doctor first treated claimant","type":"date","label":"(a) Date of your first attendance upon him in consequence of the injuries sustained","options":[],"required":true,"pdf_field":""},{"help":"Indicate if still treating claimant","type":"yes-no","label":"(b) Are you still in attendance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"State if regular doctor and duration of acquaintance","type":"text","label":"Are you his usual Medical Attendant and if so, how long have you known him and for what have you attended him ?","options":[],"required":null,"pdf_field":""},{"help":"Select cause of symptoms","type":"choice","label":"(a) Are his symptoms (i) due exclusively to the accident or (ii) traceable to disease infirmity or any other cause ?","options":["due exclusively to the accident","traceable to disease infirmity or any other cause"],"required":true,"pdf_field":""},{"help":"Indicate if claimant has history of listed diseases","type":"yes-no","label":"(b) Has he ever suffered from Gout Rheumatism, Diabetes or Fits ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide relevant medical history affecting accident or recovery","type":"text","label":"(c) Is there anything in his medical history which may have contributed directly or indirectly to the accident, or which may likely to retard his recovery","options":[],"required":null,"pdf_field":""},{"help":"State if claimant was intoxicated during accident","type":"yes-no","label":"(d) Have you any reason to support that he was under the influence of intoxicants at the time of the accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide duration of confinement to bed or house","type":"text","label":"State the time within your own knowledge that the Claimant has been as the direct and sole consequence of the injuries sustained necessarily confined to his bed room or house.","options":[],"required":null,"pdf_field":""},{"help":"State current confinement location and expected duration","type":"text","label":"If still so confined state to which and the probable duration of confinement to","options":[],"required":null,"pdf_field":""},{"help":"Indicate if claimant resumed any work","type":"yes-no","label":"(a) Has he been able to attend any portion of his business or occupation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date claimant resumed work","type":"date","label":"(b) If so from what date?","options":[],"required":null,"pdf_field":""},{"help":"Provide expected dates for resuming work and full recovery","type":"text","label":"(C) If not please, state probable date (i) of his being so able (ii) of his complete recovery","options":[],"required":null,"pdf_field":""},{"help":"State current disability status or recovery date","type":"text","label":"Is now there any disability? If not please give date of recovery","options":[],"required":null,"pdf_field":""},{"help":"Additional comments by doctor","type":"text","label":"Any further remarks","options":[],"required":false,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Doctor's full name and qualifications","type":"text","label":"Name & Qualification of Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Date of medical report","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"POLICY No","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant's medical attendant"}],"deadlines":["must be completed and returned within seven days after its receipt"],"applies_to":"Aviation Personal Accident Policy for Crew Members","attachments":["all the Medical Certificates, Reports, Discharge Summary etc."],"declarations":["I hereby declare that I have received the injuries above described and warrant the truth of the foregoing particulars in every respect.","I agree that if I have made or shall make false or untrue statement, suppression or concealment my right to compensation shall be absolutely forfeited.","The medical attendant certifies that the statements in the medical report are correct."],"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/1279-aviation-personal-accident-claim-form"}