{"id":1301,"title":"PRAVASI BHARATIYA BIMA YOJANA POLICY 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/Pravasi%20Bharatiya%20Bima%20Yojana%20Claim%20Form.pdf","sha256":"f525a745e171ceeb9ad29e877d816f275504a96fd1f5afebc3d7a033b9692497","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders under the Pravasi Bharatiya Bima Yojana to claim insurance benefits related to accidental death, disability, hospitalization, termination of employment, and other covered losses.","notes":[],"title":"PRAVASI BHARATIYA BIMA YOJANA POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"1. Insured Details","fields":[{"help":"","type":"text","label":"Full Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Telephone No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation :","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the Insured/Claimant:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"2. Foreign Employment Details","fields":[{"help":"Enter passport number","type":"text","label":"Passport No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter passport validity date","type":"date","label":"Valid up to:","options":[],"required":null,"pdf_field":""},{"help":"Provide details of work permit","type":"text","label":"Details of Work Permit","options":[],"required":null,"pdf_field":""},{"help":"Enter country name","type":"text","label":"Name of the Country for which Visa obtained:","options":[],"required":null,"pdf_field":""},{"help":"Provide employer's name and address abroad","type":"text","label":"Name and Address of the Employer abroad :","options":[],"required":null,"pdf_field":""},{"help":"Enter contract period","type":"text","label":"Period of Contract:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"3. Compensation from other sources","fields":[{"help":"","type":"yes-no","label":"Has the Insured claimed any compensation from any other source for the same loss/damage/liability?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"4. Other insurance policies held by the Insured (PA & Health)","fields":[{"help":"Provide details of other personal accident and health insurance policies","type":"text","label":"Details of other insurance policies held by the Insured (PA & Health)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"5. Details of Loss","fields":[{"help":"Enter the amount claimed","type":"amount","label":"Amount Claimed","options":[],"required":null,"pdf_field":""},{"help":"Select the type of loss","type":"choice","label":"State type of Loss- Accidental Death/Permanent Disability/Hospitalisation/Transportation Cost/Termination/Loss of Employment/Maternity Expenses/Legal Expenses","options":["Accidental Death","Permanent Disability","Hospitalisation","Transportation Cost","Termination","Loss of Employment","Maternity Expenses","Legal Expenses"],"required":null,"pdf_field":""},{"help":"Provide date, time and cause of loss","type":"text","label":"Details of Loss- (i) Date & Time (ii) Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if accident was reported to police","type":"yes-no","label":"In case loss is due to Accident, whether the same has been reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide hospitalization details and attach supporting documents","type":"text","label":"If the Loss is due to Hospitalisation due to Illness or Maternity, give details of: (i) Name of the Patient (ii) Relationship with Insured (iii) Date of Admission (iv) Date of Discharge (v) Reason for Hospitalisation (Diagnosis) (vi) Amount Claimed (vii) Attach supporting Bills, Test Reports, Prescriptions and Discharge Summary.","options":[],"required":null,"pdf_field":""},{"help":"Provide termination details, attach air ticket, boarding pass, certificate from Indian Mission/Post, and legal expense proofs","type":"text","label":"If the Claim is made on grounds of Termination of Employment, please give details of: (i) Date of Commencement of PBBY Policy (ii) Date of reporting to Foreign Employer (iii) Reasons given by Foreign Employer for termination of employment- 1. Fallen Sick/ Medically found unfit for employment (within 6 months of commencement of PBBY Policy) 2. Not received/employed by employer on arrival abroad 3. Substantive change in terms of employment/ job/employment contract (Within 3 months of taking PBBY Policy) (iv) Amount of One way Economy Class Airfare claimed (attach Original Air Ticket & Boarding Pass) (v) Submit Certificate from Indian Mission/Post certifying grounds for repatriation. (vi) Legal Expenses- Grounds for incurring along with supporting proof.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"6. Declaration and Signature","fields":[{"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":"INSURED’S SIGNATURE","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":[],"applies_to":"Claims under Pravasi Bharatiya Bima Yojana policy","attachments":["Attach supporting Bills, Test Reports, Prescriptions and Discharge Summary for hospitalization claims","Attach Original Air Ticket & Boarding Pass for airfare claims","Submit Certificate from Indian Mission/Post certifying grounds for repatriation","Attach supporting proof for Legal Expenses"],"declarations":["I / We declare that the details furnished above are correct in all aspects."],"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/1301-pravasi-bharatiya-bima-yojana-policy-claim-form"}