{"id":1313,"title":"PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) 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/CLAIMFORM-english.pdf","sha256":"9d9e63f58cd5cbb3ed53aba878708e584f10caee5669e7266262a4cca74fcad9","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming insurance benefits under the PMSBY scheme and is to be filled by the insured person or nominee in case of death.","notes":["The form is issued without admission of liability.","The claim form may be obtained from the bank branch, insurance company branches, hospitals, PHCs, BCs, insurance agents, or designated websites.","Supply of the form shall not be denied to any person requesting the same.","The authorised official of the Bank shall verify account and nomination details and certify the claim form before forwarding to the insurer.","In case of death without a nominee, claim amount will be paid to legal heirs on production of Succession Certificate/ Legal Heir certificate.","Use original documents for submission."],"title":"PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) CLAIM FORM","submit":{"to":"the branch where the insured holds the underlying Bank Account","how":"submit the completed form to the bank branch","address":""},"purpose":"claim","sections":[{"title":"Insured Person and Bank Details","fields":[{"help":"","type":"text","label":"Name of the Account holder (Insured person)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full address of the Insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and address of the Bank Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank account number linked to the PMSBY policy","type":"text","label":"Savings Bank Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number if available","type":"phone","label":"Contact details of insured (if available): Mobile No:","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number if available","type":"phone","label":"Phone number:","options":[],"required":false,"pdf_field":""},{"help":"Enter email address if available","type":"email","label":"email address:","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhar number if available","type":"text","label":"Aadhar no. if available:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or nominee"},{"title":"Nominee Details (in case of death of insured)","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile / Phone number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email address:","options":[],"required":false,"pdf_field":""},{"help":"Provide bank account details for claim payment","type":"text","label":"Bank Account Particulars (for electronic transfer):","options":[],"required":null,"pdf_field":""},{"help":"Enter Aadhar number if available","type":"text","label":"Aadhar no. if available:","options":[],"required":false,"pdf_field":""}],"filled_by":"nominee"},{"title":"Accident Details","fields":[{"help":"Provide exact date and time of accident","type":"date","label":"Day, Date, and Time of occurrence:","options":[],"required":null,"pdf_field":""},{"help":"Location of the accident","type":"text","label":"Where did it occur:","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident type","type":"text","label":"Nature of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Explain cause of death or injury details","type":"text","label":"Cause of Death/Details of Injury:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person or nominee"},{"title":"Hospital / Doctor Details","fields":[{"help":"Provide hospital and doctor contact details","type":"text","label":"Name address and contact details of Hospital/ attending Doctors:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person or nominee"},{"title":"Medical Visit Details","fields":[{"help":"Provide location and time for company officer visit","type":"text","label":"State where and when a Medical or other Officer of the Company can visit the Insured.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person or nominee"},{"title":"Declaration and Signature","fields":[{"help":"Date of signing","type":"date","label":"Dated:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant/Nominee.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Bank Certification (for office use)","fields":[{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number:","options":[],"required":null,"pdf_field":""},{"help":"Bank official to certify premium debit and remittance dates","type":"text","label":"Certified that the information relating to the Bank Account and Nominee has been verified. Premium was debited to the Bank Account on ..................... and remitted to the insurer on:..................................","options":[],"required":null,"pdf_field":""},{"help":"Bank official signature","type":"signature","label":"Signature of Authorised Official of the Bank","options":[],"required":true,"pdf_field":""}],"filled_by":"authorised official of the bank"},{"title":"Discharge Voucher","fields":[{"help":"Bank to fill claim number","type":"text","label":"Claim No. :( to be filled by Bank)","options":[],"required":null,"pdf_field":""},{"help":"Policy number","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Bank and branch name","type":"text","label":"Name of Bank / branch:","options":[],"required":null,"pdf_field":""},{"help":"Name of insured person","type":"text","label":"Name of Insured:","options":[],"required":null,"pdf_field":""},{"help":"Bank account number of insured","type":"text","label":"Bank Account No. of Insured:","options":[],"required":null,"pdf_field":""},{"help":"Date of discharge voucher signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Fill in insurance company name, claim amount, date of loss, policy number and policy period","type":"text","label":"In Consideration of approval of my claim referred above, I/We hereby accept from (name of the Insurance Company) the sum of Rs. (approved net Claim amount) in full and final settlement of my/our claim arising out of . . . . . . . . .which occurred on (date of loss) covered under Policy No. . . . . . . . .. . valid for the period from..........to......................","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Nominee /Insured.","options":[],"required":true,"pdf_field":""},{"help":"Print full name of nominee or insured","type":"text","label":"Full Name:","options":[],"required":null,"pdf_field":""},{"help":"Address of nominee or insured","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Bank account number of nominee","type":"text","label":"Account No of Nominee:","options":[],"required":null,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Witness Full Name","options":[],"required":null,"pdf_field":""},{"help":"Bank official countersignature","type":"signature","label":"Counter Signature of Authorised Official of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Bank name and branch address","type":"text","label":"Bank Name & Branch:","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""}],"filled_by":"nominee or insured"}],"deadlines":["preferably within 30 days of the accident resulting in claim","Maximum time limit for Bank to forward duly completed claim form to Insurance Company is thirty days","Maximum time limit for Insurance Company to approve claim and disburse money thereafter is thirty days"],"applies_to":"claims under the Pradhan Mantri Suraksha Bima Yojana (PMSBY) scheme","attachments":["In case of Death: Original FIR/ Panchnama, Post Mortem Report and Death Certificate.","In case of Permanent Disablement: Original FIR/ Panchnama and Disability Certificate from Civil Surgeon.","Discharge voucher"],"declarations":["The particulars given are true and complete and any false information will forfeit the right to compensation.","The claimant has not claimed the amount due under PMSBY for the same accident through any other cover.","The claimant/nominee accepts the approved claim amount as full and final settlement and subrogates all rights to the insurance company."],"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/1313-pradhan-mantri-suraksha-bima-yojana-pmsby-claim-form"}