{"id":1306,"title":"Personal Accident Insurance Claim Form (Particulars) of Accident","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/Personal%20Accident%20Claim%20form.pdf","sha256":"aa4bd5d595b4705988c80e91572cbc9cd159b4cd1c5a4aa96984dbd627b35718","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim compensation for a personal accident under their insurance policy. It collects details about the accident, injury, and medical treatment.","notes":["The issue of this form is not an admission of liability.","Claims must be supported by medical evidence furnished by the insured at his expense.","Strike out which is not applicable in the eye witness certification."],"title":"Personal Accident Insurance Claim Form (Particulars) of Accident","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured and Accident","fields":[{"help":"","type":"text","label":"Name of the Insured [in full]","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the injured Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address in full","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Profession or occupation","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age at last birthday","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Specify the table of cover applicable","type":"text","label":"Table of Cover","options":[],"required":null,"pdf_field":""},{"help":"Specify the period of insurance","type":"text","label":"Period","options":[],"required":null,"pdf_field":""},{"help":"Date when the accident occurred","type":"date","label":"Date of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Time when the accident occurred","type":"text","label":"Time of accident?","options":[],"required":null,"pdf_field":""},{"help":"Location where the accident happened","type":"text","label":"Place of Accident?","options":[],"required":null,"pdf_field":""},{"help":"Details of any witness to the accident","type":"text","label":"Name and address of witness","options":[],"required":null,"pdf_field":""},{"help":"Describe the circumstances of the accident","type":"text","label":"How did the accident occur ?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Injury and Disablement Details","fields":[{"help":"Describe the injury and specify side if applicable","type":"text","label":"Nature of injury received (If to limb or eye state whether right or left)","options":[],"required":null,"pdf_field":""},{"help":"Describe the disablement caused by the injury","type":"text","label":"Nature of disablement","options":[],"required":null,"pdf_field":""},{"help":"Select the extent of disablement","type":"choice","label":"Extent of disablement","options":["Confined to bed","Confined to house"],"required":null,"pdf_field":""},{"help":"Specify the period of incapacity","type":"date","label":"Present state of incapacity [ from ________________ To ________________]","options":[],"required":null,"pdf_field":""},{"help":"Details of the surgeon treating the injury","type":"text","label":"Name and address of surgeon in attendance","options":[],"required":null,"pdf_field":""},{"help":"Provide location and time for medical officer visit","type":"text","label":"Where and when can a Medical Officer of the Company visit you, if necessary ?","options":[],"required":null,"pdf_field":""},{"help":"Nearest railway station and distance from your location","type":"text","label":"Name of nearest railway station and distance therefrom","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other accident insurance coverage","type":"text","label":"Are you insured in any other office or offices granting compensation for accident If so state name and address of company or companies and amount of insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Name of the witness to the declaration","type":"text","label":"Witness: Name","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Certification by Eye Witness","fields":[{"help":"Name of the injured person","type":"text","label":"I hereby certify that I was present when the Accident occurred to Mr.","options":[],"required":null,"pdf_field":""},{"help":"Date of accident","type":"date","label":"On the day of","options":[],"required":null,"pdf_field":""},{"help":"Cause of the accident","type":"text","label":"It was caused by","options":[],"required":null,"pdf_field":""},{"help":"Select applicable option","type":"choice","label":"Was / was not under the influence of intoxicating liquor at the time (strike out which is not applicable)","options":["was","was not"],"required":null,"pdf_field":""},{"help":"Signature of the eye witness","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Address of the eye witness","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Occupation of the eye witness","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Date of signing by the eye witness","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"eye witness"},{"title":"Medical Certificate","fields":[{"help":"Name of the person claiming","type":"text","label":"Name of Claimant","options":[],"required":null,"pdf_field":""},{"help":"Gender of the claimant","type":"choice","label":"Sex","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Age of the claimant","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident and cause","type":"text","label":"Nature and cause of accident","options":[],"required":null,"pdf_field":""},{"help":"Specify side of injury if applicable","type":"text","label":"If to eye or limb, state left or right","options":[],"required":null,"pdf_field":""},{"help":"Confirm if injuries match the accident description","type":"yes-no","label":"Whether the appearance of the Injuries are consistent with the account given of the accident.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of first medical attendance","type":"date","label":"Date on which you first attended Claimant for this injury","options":[],"required":null,"pdf_field":""},{"help":"Duration claimant was unable to work","type":"text","label":"Has Claimant been totally prevented from attending to any portion of his business ? If so how long ?","options":[],"required":null,"pdf_field":""},{"help":"Details of any other illness affecting recovery","type":"text","label":"Is Claimant suffering from any disease or illness apart From his injury and is there any illness by circumstances Which may tend to retard recovery? If so, give particulars?","options":[],"required":null,"pdf_field":""},{"help":"Current medical condition of the claimant","type":"text","label":"Present Condition","options":[],"required":null,"pdf_field":""},{"help":"Estimated duration of total disablement","type":"text","label":"How long from the happening of the Accident do you consider Total disablement will last ?","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature certifying the details","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Doctor's full name and qualification","type":"text","label":"Name & Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Date of medical certificate","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Additional remarks by the doctor","type":"text","label":"REMARKS FOR EXTRA DETAILS","options":[],"required":false,"pdf_field":""}],"filled_by":"attending doctor"}],"deadlines":[],"applies_to":"Personal Accident Insurance claims","attachments":["Medical Evidence furnished by the Insured at his expense"],"declarations":["The insured declares that all statements are true and nothing is concealed.","The insured agrees that any false or fraudulent statement will void the policy and forfeit compensation.","The insured agrees to make a statutory declaration if required.","The eye witness certifies presence at the accident and truthfulness of the account.","The attending doctor certifies the medical details and disablement."],"dropped_labels":1},"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/1306-personal-accident-insurance-claim-form-particulars-of-accident"}