{"id":1370,"title":"AVIATION PERSONAL ACCIDENT POLICY (For Pilots, Navigators, Aircraft Flight Engineers, Aircraft Flight Technicians & other Crew Members) CLAIM FORM","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/aviation-personal-accident-policy/claim-form.pdf","sha256":"c6ac633ffa43a8e329965310910220d3369a41982e8bc46c262f57b1691d1cb3","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by insured crew members or claimants to file a claim under the Aviation Personal Accident Insurance Policy for accidents, injuries, disability, or death. It is filled by the insured person, claimant, employer (for group policies), and medical attendant.","notes":["All questions must be answered fully; use a separate sheet if space is insufficient.","Incomplete or blank sections will cause the form to be returned.","The issue or acceptance of this form is not an admission of liability by the insurer.","Medical attendant must affix official seal/stamp on the certificate.","Documents listed must be attached for claim processing."],"title":"AVIATION PERSONAL ACCIDENT POLICY (For Pilots, Navigators, Aircraft Flight Engineers, Aircraft Flight Technicians & other Crew Members) CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. The Insured","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Office telephone number","type":"phone","label":"Tel No.Office :","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"B. Policy Details","fields":[{"help":"Policy number as per insurance documents","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Start and end date of insurance coverage","type":"date","label":"Period of Insurance: to","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"C. Claimant","fields":[{"help":"Name of the claimant","type":"text","label":"(a)  Name:","options":[],"required":true,"pdf_field":""},{"help":"Full postal address of claimant","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Office telephone number","type":"phone","label":"Tel No.Office :","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Relationship to the insured person","type":"text","label":"Relationship with insured person","options":[],"required":true,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"(b) Insured person’s details Name:","options":[],"required":true,"pdf_field":""},{"help":"Select gender of insured person","type":"choice","label":"Sex: Male  Female ","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Date of birth of insured person","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Occupation of insured person","type":"text","label":"Occupation:","options":[],"required":true,"pdf_field":""},{"help":"ID number if applicable","type":"text","label":"Employee/Member identification number (for group policies)","options":[],"required":false,"pdf_field":""},{"help":"Address for medical visits","type":"text","label":"Address where a Medical Practitioner on behalf of USGI can visit","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"D. Accident Details","fields":[{"help":"Date when accident occurred","type":"date","label":"Date of accident: (dd/mm/yy)","options":[],"required":true,"pdf_field":""},{"help":"Time of accident with am/pm","type":"text","label":"Time of accident:","options":[],"required":true,"pdf_field":""},{"help":"Select if accident occurred at work","type":"choice","label":"Did it occur at work: Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Where did the accident occur","options":[],"required":true,"pdf_field":""},{"help":"Description of accident circumstances","type":"text","label":"How did the accident happen","options":[],"required":true,"pdf_field":""},{"help":"Whether police was informed","type":"choice","label":"Was the accident reported to Police Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Reason for not reporting to police","type":"text","label":"If not, kindly state the reasons","options":[],"required":false,"pdf_field":""},{"help":"Whether witnesses were present","type":"choice","label":"Are there any witnesses to the accident Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Names and contacts of witnesses","type":"text","label":"If yes, kindly provide name(s) and contact details","options":[],"required":false,"pdf_field":""},{"help":"Details of injuries sustained","type":"text","label":"Describe the nature of injuries received","options":[],"required":true,"pdf_field":""},{"help":"Start and end dates of total disability","type":"date","label":"Period of disability: Total disability- confined to Bed:  (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Start and end dates of partial disability","type":"date","label":"Partial disability – confined to House (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"List duties not performable due to disability","type":"text","label":"If partially disabled, kindly state the daily duties of usual occupation which cannot be performed","options":[],"required":false,"pdf_field":""},{"help":"Date and time of death if applicable","type":"text","label":"In case of death of insured person, kindly provide following information: Date and time of death","options":[],"required":false,"pdf_field":""},{"help":"Whether post-mortem was done","type":"choice","label":"Whether post-mortem was conducted Yes  No ","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Reason for no post-mortem","type":"text","label":"If not, please give reason","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"E. Hospitalisation/treatment Details","fields":[{"help":"Doctor's name and contact info","type":"text","label":"Name & contact details of doctor first consulted after the accident","options":[],"required":true,"pdf_field":""},{"help":"Other doctors consulted","type":"text","label":"Name and contact details of other doctors consulted","options":[],"required":false,"pdf_field":""},{"help":"Usual medical practitioner details","type":"text","label":"Name and contact details of claimant’s usual medical practioner","options":[],"required":false,"pdf_field":""},{"help":"Whether claimant was hospitalized","type":"choice","label":"Whether hospitalized following the accident Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Hospital name and address","type":"text","label":"If Yes, name & address of hospital","options":[],"required":false,"pdf_field":""},{"help":"Hospitalization start and end dates","type":"date","label":"Period of hospitalization: (dd/mm/yy) to","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"F. Other Insurances","fields":[{"help":"Name of other insurance company","type":"text","label":"Name of insurer","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Coverage period of other insurance","type":"text","label":"Period of insurance","options":[],"required":false,"pdf_field":""},{"help":"Type of coverage under other insurance","type":"text","label":"Coverage","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other insurance","type":"amount","label":"Sum insured","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"G. Declaration","fields":[{"help":"Sign to confirm declaration","type":"signature","label":"Signature of Insured/claimant:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"To be completed by Employer (for Group Policies)","fields":[{"help":"Name of employee","type":"text","label":"Mr./Ms","options":[],"required":true,"pdf_field":""},{"help":"Employee's designation","type":"text","label":"working as","options":[],"required":true,"pdf_field":""},{"help":"Employee ID number","type":"text","label":"permanent Employee Id No.","options":[],"required":true,"pdf_field":""},{"help":"Group policy number","type":"text","label":"covered under Group Personal Accident Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Leave period dates","type":"date","label":"was on leave for the period to","options":[],"required":false,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"Capital Sum insured of Rs.","options":[],"required":true,"pdf_field":""},{"help":"Number of permanent employees","type":"number","label":"The total number of employees on permanent rolls as on the date of accident was","options":[],"required":true,"pdf_field":""},{"help":"Employer's authorized signature","type":"signature","label":"Signature of Authorised signatory:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Name and designation of signatory","type":"text","label":"Name & Designation of Authorized signatory:","options":[],"required":true,"pdf_field":""},{"help":"Company seal or stamp","type":"attachment","label":"Company Seal:","options":[],"required":true,"pdf_field":""}],"filled_by":"employer"},{"title":"Medical Attendant’s Certificate","fields":[{"help":"Patient's full name","type":"text","label":"Name of patient:","options":[],"required":true,"pdf_field":""},{"help":"Patient's occupation","type":"text","label":"Occupation:","options":[],"required":false,"pdf_field":""},{"help":"Duration of medical relationship","type":"text","label":"How long have you known this patient","options":[],"required":false,"pdf_field":""},{"help":"Whether usual medical attendant","type":"choice","label":"Are you his/her usual Medical Attendant Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe injuries and extent","type":"text","label":"Kindly state the nature of and extent of injuries","options":[],"required":true,"pdf_field":""},{"help":"Confirm injury matches claimant's description","type":"choice","label":"Is the injury consistent with claimant’s description of the accident Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Whether injuries relate to prior conditions","type":"choice","label":"Are the injuries connected with any previous accident, infirmity or disease Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of previous conditions","type":"text","label":"If yes, please provide details","options":[],"required":false,"pdf_field":""},{"help":"Whether recovery will be delayed","type":"choice","label":"Will the recovery be retarded due to above Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details on delayed recovery","type":"text","label":"If yes, kindly provide details","options":[],"required":false,"pdf_field":""},{"help":"Date of first consultation","type":"date","label":"When were you first consulted for this injury/disability (dd/mm/yy)","options":[],"required":true,"pdf_field":""},{"help":"Other doctors consulted","type":"text","label":"Please give details of other consultations – Dr’s name, address","options":[],"required":false,"pdf_field":""},{"help":"Whether treatment is ongoing","type":"choice","label":"Are you still treating the patient for the injury/disability Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Treatment details","type":"text","label":"Kindly provide details of treatment prescribed","options":[],"required":false,"pdf_field":""},{"help":"X-ray findings and report","type":"text","label":"If X-ray has been done, kindly state the findings and Radiologist’s report","options":[],"required":false,"pdf_field":""},{"help":"Hospital name if applicable","type":"text","label":"If hospitalized, name of hospital","options":[],"required":false,"pdf_field":""},{"help":"Hospitalization dates","type":"date","label":"Period of hospitalization   (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Surgery date and details","type":"text","label":"Date & Nature of surgical procedure, if any  (dd/mm/yy)","options":[],"required":false,"pdf_field":""},{"help":"Complications details","type":"text","label":"Are there any complications which may retard the recovery","options":[],"required":false,"pdf_field":""},{"help":"Previous similar injury","type":"choice","label":"Has the patient suffered from similar injury/disability previously? Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of previous injury","type":"text","label":"If yes, when, nature and duration of the","options":[],"required":false,"pdf_field":""},{"help":"Whether patient was intoxicated","type":"choice","label":"Was the patient under the influence of intoxicants or drugs at the time of accident Yes  No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Period of total disability","type":"date","label":"While under your care and direction, how long was or will the patient be: a) Totally unable to perform each and every duty of his/her usual occupation From (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Period of partial disability","type":"date","label":"b) Partially disabled from performing his/her usual occupation (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Description of permanent total disability","type":"text","label":"Nature of disablement (in case of permanent disability) Permanent Total disability","options":[],"required":false,"pdf_field":""},{"help":"Details and percentage of permanent partial disability","type":"text","label":"Permanent partial disability, If yes, give details and percentage of disability","options":[],"required":false,"pdf_field":""},{"help":"Cause of death if applicable","type":"text","label":"In case of death of insured person, kindly state the cause of death","options":[],"required":false,"pdf_field":""},{"help":"Additional comments on recovery","type":"text","label":"Prognosis Please comment on any additional factor that may prolong recovery from injury/disability","options":[],"required":false,"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":"Medical attendant's qualification","type":"text","label":"Qualification:","options":[],"required":true,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Reg.No.:","options":[],"required":true,"pdf_field":""},{"help":"Medical attendant's address","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Date of certificate","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"medical attendant"}],"deadlines":[],"applies_to":"Claims under Aviation Personal Accident Policy for Pilots, Navigators, Aircraft Flight Engineers, Aircraft Flight Technicians & other Crew Members","attachments":["Police Report/Panchnama","Post Mortem Report","Death Certificate","Copies of record of treatment including X rays, investigation reports","Cash memos, Bills and receipts in case medical expenses are covered","Any other document as may be required"],"declarations":["The insured/claimant guarantees the truthfulness of the statements and understands that false statements may cancel the policy and claims.","The company may verify identity, address, facts and documents with third parties.","The insured/claimant agrees to the company's privacy policy as amended from time to time.","The insured/claimant understands the need to submit all required documents to avoid delays in claim processing.","All persons having interest in the property are disclosed and no duplicate claims have been made.","Consent is given to verify identity/address/bank details through Central KYC Registry or UIDAI or other modes.","Authorization is given to hospitals and medical providers to furnish medical details to the insurer.","Employer certifies employment details and coverage for group policies.","Medical attendant certifies the accuracy of medical information and treatment details."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"contactclaims@universalsompo.com","label":"Claims Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"e Claim Details\nTPA’s Servicing Group Health Insurance\nDownload Pulz App\nConnect with Us\ncontactus@universalsompo.com\ncontactclaims@universalsompo.com\nHealth Insurance :\nComplete Healthcare Insurance\nA Plus Health Insurance\nSaral Suraksha Bima\nGroup Mashak Rakshak Polic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"contactus@universalsompo.com","label":"Theft Claim Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.universalsompo.com/claimintimation/","quote":"ntimate claim.\nFor\nTheft Claim\n, please connect with us on below details.\nPhone:\n1800-22-4030\n,\n1800-200-4030\nor\nEmail:\ncontactus@universalsompo.com\nOk\nView All Policies\nHealth Insurance\nComplete Healthcare Insurance\nSuper Healthcare Insurance\nArogya SanjeevaniInsuran","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-22-4030","label":"Claims Toll Free Number (MTNL/BSNL Lines)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/claims/","quote":null,"fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022-41582900 - 41582999","label":"Claims Helpline Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/claims/","quote":"tactclaims@universalsompo.com 2. Call on our Toll Free number 1-800-22-4030 (from MTNL & BSNL Lines) 3. Helpline number 022-41582900 - 41582999\nIn case of telephonic contact, our call centre executive shall note down the basic requirements and pass on the informa","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-200-4030","label":"Motor Claim Intimation Toll Free","level":null,"hours":"24/7","applies_to":"motor","source_url":"https://www.universalsompo.com/claimintimation/","quote":"Motor Claim Intimation for Coverage | Universal Sompo\n24/7, Customer Care\n1800-22-4030\n,\n1800-200-4030\nCrop Helpline No.\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout\r\n                                us\nContact Us\nLogin","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-200-5142","label":"Crop Helpline Number","level":null,"hours":null,"applies_to":"crop","source_url":"https://www.universalsompo.com/claimintimation/","quote":"otor Claim Intimation for Coverage | Universal Sompo\n24/7, Customer Care\n1800-22-4030\n,\n1800-200-4030\nCrop Helpline No.\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout\r\n                                us\nContact Us\nLogin\nI am a Customer\nI am an Agent\nP","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/universal-sompo-general-insurance/1370-aviation-personal-accident-policy-for-pilots-navigators-aircraft-flight-engineer"}