{"id":1332,"title":"JANATA PERSONAL ACCIDENT INSURANCE 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/Rural%20%26%20Social%20-%20Janata%20Personal%20Accident%20Insurance_2.pdf","sha256":"8692356d777a443a62bc3296f686cf6bba951dc0a5ac7f956a94f46b47e41e6d","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used to claim benefits under the Janata Personal Accident Insurance policy. It is filled by the insured person, hospital authorities, and assignee in case of death.","notes":[],"title":"JANATA PERSONAL ACCIDENT INSURANCE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION I (TO BE FILLED IN FOR ALL CLAIMS)","fields":[{"help":"","type":"text","label":"a) Insured’s Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"c) Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Policy coverage period","type":"text","label":"b) Period","options":[],"required":null,"pdf_field":""},{"help":"Place where policy was issued","type":"text","label":"c) Issued at","options":[],"required":null,"pdf_field":""},{"help":"Brief description of the accident","type":"text","label":"a) Particulars of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Date and time of accident, place, and whether police was informed","type":"text","label":"b) Details Date Time A.M./P.M. Place Whether reported to police Yes/ No.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"a) Were you removed to hospital immediately after the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name and address of hospital if admitted","type":"text","label":"b) If yes, Name & address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"a) Do you have any other Janatha Personal Accident Policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other Janatha Personal Accident policies if any","type":"text","label":"If yes, please give: 1. Name of the company 1. Address of the issuing office 2. Policy No. 3. Period","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION II (TO BE COMPLETED BY HOSPITAL AUTHORITIES)","fields":[{"help":"","type":"text","label":"Name & address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Select the type of case","type":"choice","label":"As in – patient / out patient / emergency case","options":["in-patient","out-patient","emergency case"],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Describe injury and treatment details","type":"text","label":"Nature of injury Particulars of treatment","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"a) Has the accident resulted into loss of hand/s or foot/feet or eye/s or permanent disability of any other type which may prevent the Insured from engaging in or being occupied with or giving attention to any employment or occupation whatsoever?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of permanent disability if any","type":"text","label":"b) If yes, please give details","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Competent Authority of Hospital / Nursing Home","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of the signing authority","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Official hospital stamp","type":"attachment","label":"Rubberstamp of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Designation of the signing authority","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"},{"title":"SECTION III (TO BE COMPLETED BY ASSIGNEE IN THE EVENT OF INSURED’S DEATH)","fields":[{"help":"","type":"text","label":"a) Full Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"c) Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"d) Relationship with the deceased","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Assignee","options":[],"required":null,"pdf_field":""}],"filled_by":"assignee"},{"title":"Documents to Attach","fields":[{"help":"Attach these documents if applicable","type":"attachment","label":"Please attach the following documents:- 1. Death Certificate 2. Post Mortem Report 3. Original Policy document with receipt","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration","fields":[{"help":"Read and agree to the declaration below","type":"text","label":"Declaration to be signed by the Insured/ Claimant or by the Assignee (in the event of Insured’s death)","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"I/WE HEREBY DECLARE and warrant the truth of the foregoing particulars in every respect.","options":["Agree"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"I / We agree that if / I / we have made, or if, shall make false or untrue statement, suppression or concealment, my/our right to compensation shall be forfeited.","options":["Agree"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"I/WE ALSO HEREBY DECLARE that I am /we are accepting the amount in full discharge of your obligations under the policy to the Insured and / or his/her legal heirs and I/we will hold you indemnified in the event of any claim under this policy being made against you by any other person or persons.","options":["Agree"],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant or assignee"}],"deadlines":[],"applies_to":"Janata Personal Accident Insurance claims","attachments":["Death Certificate","Post Mortem Report","Original Policy document with receipt"],"declarations":["The claimant declares the truth of all particulars given.","False or untrue statements or concealment will forfeit the right to compensation.","The claimant accepts the amount as full discharge of the insurer's obligations and indemnifies the insurer against other claims."],"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/1332-janata-personal-accident-insurance-claim-form"}