{"id":1321,"title":"CLAIM FORM - ANIMAL DRIVEN CART INSURANCE","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/Rural%20%26%20Social%20-%20Animal%20Driven%20Cart%20Insurance_1.pdf","sha256":"1518af937cdc37347eb29aefe3a2f356c97949c67c8fcadfc881f684e5a7ddc0","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Animal Driven Cart Insurance policy and is to be filled by the insured or claimant.","notes":["The issue of this form does not constitute admission of liability.","The fee, if any, for the Medical Report will be borne by the Insured Person."],"title":"CLAIM FORM - ANIMAL DRIVEN CART INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Name of insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"c) Business / Occupation:","options":[],"required":null,"pdf_field":""},{"help":"List any other persons with interest in the insured property","type":"text","label":"d) Name of other persons having an Interest in the property","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Insurance","fields":[{"help":"List all policy numbers including those with other companies","type":"text","label":"Policy No. (s)","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum Insured Rs.","options":[],"required":null,"pdf_field":""},{"help":"Policy start date","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""},{"help":"Policy end date","type":"date","label":"To","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Section I - Animal & Cart / Vehicle","fields":[{"help":"Provide details below","type":"text","label":"A) LOSS OR DAMAGE TO CART / VEHICLE -DETAILS OF LOSS / EVENT","options":[],"required":null,"pdf_field":""},{"help":"Specify exact time and date of loss or event","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss or event","type":"text","label":"b) Cause of Loss / Event","options":[],"required":null,"pdf_field":""},{"help":"Describe the insured item affected","type":"text","label":"c) Item of Policy effected (give description)","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description of the event","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":null,"pdf_field":""},{"help":"Indicate if reported to authorities","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide estimated repair cost","type":"amount","label":"f) Estimate of repairs to the cart / vehicle.","options":[],"required":null,"pdf_field":""},{"help":"Name of the person or workshop repairing the cart/vehicle","type":"text","label":"g) Name of repairer.","options":[],"required":null,"pdf_field":""},{"help":"Provide details below","type":"text","label":"B) INJURY TO ANIMAL","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident or event causing injury","type":"text","label":"a) Was the animal injured due to any accident or event? If so, give full description of the accident / event.","options":[],"required":null,"pdf_field":""},{"help":"Name of veterinary doctor or clinic","type":"text","label":"b) Was the animal given veterinary treatment? If so, by whom.","options":[],"required":null,"pdf_field":""},{"help":"Describe disablement with veterinary support","type":"text","label":"c) Was the animal disabled due to the said accident? If so, describe the nature of disablement supported by the attending Veterinary Doctor.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Section II - Third Party Liability","fields":[{"help":"Provide date, time and location of accident","type":"text","label":"a) Date hour and place of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of accident in detail","type":"text","label":"b) Cause of accident (Full information)","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries or damages caused","type":"text","label":"c) Nature and extent of injury or damage","options":[],"required":null,"pdf_field":""},{"help":"Provide details of injured persons","type":"text","label":"d) Name, address and age of injured person/s","options":[],"required":null,"pdf_field":""},{"help":"Details of injuries sustained","type":"text","label":"e) Particulars of accidental bodily injury of the injured","options":[],"required":null,"pdf_field":""},{"help":"Provide owner details of damaged property","type":"text","label":"f) Name and address of owner of third party property damaged","options":[],"required":null,"pdf_field":""},{"help":"Indicate if injured person is your employee","type":"yes-no","label":"g) Is he / she in your service","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"State compensation expected by third party","type":"text","label":"h) Details of compensation expected","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any claim communication","type":"text","label":"i) Has any communication, verbal or written made to you for any claim from third party? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Describe any settlement or compromise","type":"text","label":"j) Details of compromise made if any.","options":[],"required":null,"pdf_field":""},{"help":"Date and person reporting accident","type":"text","label":"k) When and by whom was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if reported to police or authority","type":"yes-no","label":"l) Has the accident been reported to Policy or Public Authority?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide witness details","type":"text","label":"m) Name/s and address/es of the witnesses to the accident.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Section III - Personal Accident to Driver","fields":[{"help":"Provide details below","type":"text","label":"DETAILS OF LOSS / EVENT","options":[],"required":null,"pdf_field":""},{"help":"Specify time and date of loss/event","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss/event","type":"text","label":"b) Cause of Loss / Event","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of event","type":"text","label":"c) Describe in detail the total event giving rise to the claim","options":[],"required":null,"pdf_field":""},{"help":"Indicate if reported to authorities","type":"yes-no","label":"d) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide driver's name and age","type":"text","label":"e) Name of the driver and age.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if driver was hospitalized immediately","type":"yes-no","label":"f) Was the driver removed to hospital immediately after the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital details if driver was admitted","type":"text","label":"g) If yes, name and address of the hospital.","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries sustained by driver","type":"text","label":"h) Nature of injury suffered by the driver due to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Medical outcome and disablement details","type":"text","label":"i) Result of the medical treatment i.e. whether the driver was disabled due to the accident and if so, the nature of disablement duly certified by the hospital.","options":[],"required":null,"pdf_field":""},{"help":"Provide assignee details if driver deceased","type":"text","label":"j) Name and age of the assignee in case of death of the driver.","options":[],"required":null,"pdf_field":""},{"help":"Relationship of assignee to driver","type":"text","label":"k) Relationship with the diseased driver.","options":[],"required":null,"pdf_field":""},{"help":"Assignee's full address","type":"text","label":"l) Full address of the assignee.","options":[],"required":null,"pdf_field":""},{"help":"Attach death certificate and post-mortem report if applicable","type":"yes-no","label":"m) Have you enclosed death certificate and post-mortem report? If so, please attach the same.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration","fields":[{"help":"Sign to declare truthfulness of information","type":"signature","label":"I/We hereby declare that the statement made by us in the claim form are true to the best of our knowledge and belief and that I / We have to withheld any material information which has bearing upon the claim.","options":[],"required":true,"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":"Claimant's signature","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Report (For Disablement Claim of Driver)","fields":[{"help":"Name and address of the insured driver","type":"text","label":"1. Name and Address of Insured Person:","options":[],"required":null,"pdf_field":""},{"help":"Describe the injury","type":"text","label":"2. What was the injury?","options":[],"required":null,"pdf_field":""},{"help":"Date of first medical attendance","type":"date","label":"3. a) When did you first attend on the Insured person following the injury?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of prior treatment if any","type":"text","label":"4. Are you his usual Medical Attendant? If you have treated him for any previous illness or injury, please give details:","options":[],"required":null,"pdf_field":""},{"help":"Duration of confinement","type":"text","label":"5. a) According to you, how long the Insured Person was confined to bed/house as the direct and sole consequence of the above injury?","options":[],"required":null,"pdf_field":""},{"help":"Additional comments","type":"text","label":"6. Any other remarks you wish to make:","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Medical Attendant's signature","type":"signature","label":"Signature:","options":[],"required":true,"pdf_field":""},{"help":"Medical Attendant's name","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Official seal or stamp of Medical Attendant","type":"attachment","label":"Seal / Rubber Stamp","options":[],"required":true,"pdf_field":""},{"help":"Medical Attendant's address","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Medical Attendant's qualifications","type":"text","label":"Qualifications:","options":[],"required":true,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Regn. No.","options":[],"required":true,"pdf_field":""}],"filled_by":"Medical Attendant"}],"deadlines":["Please return this form completed within 14 days of the loss together with the relevant documents."],"applies_to":"Animal Driven Cart Insurance claims","attachments":["Copies of policies if insurance is effected with other companies","Death certificate and post-mortem report (if applicable)","Medical report for disablement claim of driver"],"declarations":["The claimant declares that the statements made in the claim form are true to the best of their knowledge and belief.","The claimant declares that no material information has been withheld which has bearing upon the claim.","The Medical Attendant certifies the injury and treatment details provided are true."],"dropped_labels":3},"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/1321-claim-form-animal-driven-cart-insurance"}