{"id":135,"title":"CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE","purpose":"claim","insurer":{"slug":"galaxy-health-insurance","name":"Galaxy Health Insurance Company Limited"},"source_pdf":"https://www.galaxyhealth.com/assets/preloaded/GHI%2520PA%2520REIMBURSEMENT%2520CLAIM%2520FORM%2520FINAL%2520-%252017-10-2024_0.pdf","sha256":"78538debd87b16f390b7a0bcb9bfac78bf6dbf26a6118eb9e61590ea38faac2b","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to file a personal accident insurance claim with Galaxy Health Insurance Company Limited.","notes":["All fields in Section F (Payee Details) are mandatory.","Attach a cancelled cheque for the bank account mentioned.","Use original documents for submission.","The form must be duly filled and signed by the insured/claimant and treating doctor as applicable."],"title":"CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A – DETAILS OF INSURED","fields":[{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Include country and area code if applicable","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Details of Claimant (if different than insured)","fields":[{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"SECTION B – DETAILS OF ACCIDENT","fields":[{"help":"DD/MM/YYYY format","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Specify time of accident","type":"text","label":"Time of Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe cause briefly","type":"text","label":"Cause of Accident","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed description","type":"text","label":"Details of Accident","options":[],"required":null,"pdf_field":""},{"help":"Location where accident occurred","type":"text","label":"Place/Address of Accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"SECTION C – DETAILS OF WITNESS","fields":[{"help":"","type":"yes-no","label":"Were there any witness to the accident? (If ‘Yes’, provide details)","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of witness","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of witness","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact details of witness","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"SECTION D - POLICE REPORT DETAILS","fields":[{"help":"","type":"yes-no","label":"Has the loss been reported to the police authority?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"MLC number if applicable","type":"text","label":"Medico Legal Case (MLC) No.","options":[],"required":null,"pdf_field":""},{"help":"Date of police report","type":"date","label":"Report Date","options":[],"required":null,"pdf_field":""},{"help":"Police station contact number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date if applicable","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Hospital discharge date if applicable","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"SECTION E – DETAILS OF OTHER INSURANCE","fields":[{"help":"","type":"yes-no","label":"Is the accident covered under any other insurance?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"If yes, Name of insurance company","options":[],"required":null,"pdf_field":""},{"help":"Other policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Start date of other policy","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"SECTION F – PAYEE DETAILS","fields":[{"help":"Name of person to receive payment","type":"text","label":"Payee Name","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for payment","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC code","options":[],"required":true,"pdf_field":""},{"help":"Bank MICR number","type":"text","label":"MICR No.","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"SECTION H – ANY OTHER INFORMATION YOU WISH TO PROVIDE","fields":[{"help":"Optional additional details","type":"text","label":"Any other information you wish to provide","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"ANNEXURE 1: TO BE COMPLETED BY NOMINEE IN THE EVENT OF INSURED’S DEATH","fields":[{"help":"","type":"text","label":"Name of Nominee","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"nominee"},{"title":"ANNEXURE 2: MEDICAL CERTIFICATE (to be filled by treating doctor)","fields":[{"help":"","type":"text","label":"Name and address of insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Date of birth or age","type":"date","label":"Date of Birth/Age","options":[],"required":null,"pdf_field":""},{"help":"Describe accident and injuries","type":"text","label":"Nature of the Accident and details of injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cause of accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are the injuries solely due to accident?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Traceable to any disease? If yes, give details","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Traceable to any previous injury? If yes, give details","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nature of Disablement","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of Disablement","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of treatment given","options":[],"required":null,"pdf_field":""},{"help":"Duration of confinement","type":"text","label":"According to you, how long should the injured person be confined to bed/house as the direct and sole consequence of the injury sustained?","options":[],"required":null,"pdf_field":""},{"help":"Specify date if yes","type":"text","label":"During this period, will the injured person be able to attend to his/her normal duties? If yes, from date","options":[],"required":null,"pdf_field":""},{"help":"Probable date of recovery","type":"text","label":"If 'No', please state probable date of his / her being able to attend to his normal duties","options":[],"required":null,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's email","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""},{"help":"Doctor to sign and stamp","type":"signature","label":"Signature of the doctor with stamp","options":[],"required":null,"pdf_field":""},{"help":"Hospital stamp","type":"attachment","label":"Stamp of hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"SECTION I - ENCLOSURES CHECKLIST","fields":[{"help":"Attach all applicable documents","type":"checkbox","label":"Enclosures checklist","options":["Original Legal Heir Certificate (in case nomination has not been filled by deceased)","Death Certificate","Post Mortem Report","Death Summary","Claim form duly filled & signed","Claim Intimation","Police Investigation Report","Copy of FIR (First Information Report) / Spot Panchnama / Inquest Panchnama","Disability Certificate from appropriate government authority","Leave Certificate from the employer","Treatment Papers","Photograph of the injured with reflecting disablement","Medical Certificate from treating doctor","Investigation Reports"],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"}],"deadlines":[],"applies_to":"Personal accident insurance claims","attachments":["Original Legal Heir Certificate (in case nomination has not been filled by deceased)","Death Certificate","Post Mortem Report","Death Summary","Claim form duly filled & signed","Claim Intimation","Police Investigation Report","Copy of FIR (First Information Report) / Spot Panchnama / Inquest Panchnama","Disability Certificate from appropriate government authority","Leave Certificate from the employer","Treatment Papers","Photograph of the injured with reflecting disablement","Medical Certificate from treating doctor","Investigation Reports","Cancelled cheque pertaining to the bank account"],"declarations":["The issue of this form is not to be taken as an admission of liability.","The policyholder/claimant agrees to inform Galaxy Health Insurance Company Limited in writing about any changes in bank account details.","The insured/claimant warrants the truth of the statements and agrees that any false or fraudulent statement will forfeit the claim.","The nominee declares the truth of the particulars and accepts the amount in full discharge of the insurer's obligations.","The treating doctor declares the truth of the medical particulars and agrees that false statements will forfeit compensation."],"dropped_labels":13},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"support@galaxyhealth.com","label":"General Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/claims/cashless-claim","quote":"(P), #471, Anna Salai, Nandanam,\nChennai - 600 035.\nCIN: U65120TN2023PLC165765 | IRDAI Registration Number: 167\nEmail: support@galaxyhealth.com |\nToll Free Number: 1800 203 0007\nCompany\nAbout Us\nWork With Us\nAgent Registration\nContact Us\nMedia Center\nServices\nNet","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"reimbursement@galaxyhealth.com","label":"Reimbursement Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"Claims\nFor Cashless claims.\ncashless@galaxyhealth.com\nReimbursement Claims\nFor Reimbursement related Claim Assistance.\nreimbursement@galaxyhealth.com\nCashless Everywhere Claims\nGet Cashless facility for claim in Non-Network Hospital.\nanywherecashless@galaxyhealth.com\nH","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 203 0007","label":"Toll Free Number for Claims","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/claims/cashless-claim","quote":"Cashless Health Insurance Claim Process | Galaxy Health Insurance\nToll Free Number: 1800 203 0007\nProducts\nHealth Insurance\nGalaxy Marvel\nGalaxy Promise\nGalaxy Twin 360\nArogya Sanjeevani Policy, Galaxy Health Insuranc","fetched_at":"2026-10-20"},{"purpose":"cashless","channel":"email","value":"cashless@galaxyhealth.com","label":"Cashless Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"enior Citizens\nFor Claims Assistance.\nsr.citizens@galaxyhealth.com\n1800 203 0007\nCashless Claims\nFor Cashless claims.\ncashless@galaxyhealth.com\nReimbursement Claims\nFor Reimbursement related Claim Assistance.\nreimbursement@galaxyhealth.com\nCashless Everywhere Cla","fetched_at":"2026-10-20"},{"purpose":"cashless","channel":"email","value":"anywherecashless@galaxyhealth.com","label":"Cashless Everywhere Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"nce.\nreimbursement@galaxyhealth.com\nCashless Everywhere Claims\nGet Cashless facility for claim in Non-Network Hospital.\nanywherecashless@galaxyhealth.com\nHospital Empanelment\nFor Hospital Network and Empanelment Enquiry.\nserviceprovider@galaxyhealth.com\n044 4001 7232\nMonda","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/galaxy-health-insurance/135-claim-form-for-personal-accident-insurance"}