{"id":140,"title":"CLAIM FORM","purpose":"claim","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/saral-suraksha-bima,-generali-central-insurance-company-limited/claim-forms/saral-suraksha-bima-gci-claim-form.pdf","sha256":"61e0dd0b83442e778f7b8054aab22624ac5f335a4ad3e8cda5541c6b8c301bc5","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant or insured person to file a claim under the Saral Suraksha Bima policy with Generali Central Insurance Company Limited.","notes":["Use original bills only.","Attach all original bills, receipts, credit card slips or bank statements to your claim (mandatory).","Issuance of the form does not imply acceptance of liability or waiver of policy terms, conditions & exclusions.","Please attach a scanned image of a blank, duly cancelled cheque for NEFT payment.","Contact the 24 hour Helpline Number +91 22 67347841 or country specific numbers for assistance."],"title":"CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Claimant Details","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Passport No","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Policy Start Date","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Policy End date","options":[],"required":null,"pdf_field":""},{"help":"List other policy numbers if any","type":"text","label":"Please Indicate any other insurance coverage (In India/ overseas): Policy Number/ s","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Person (in whose name the policy is issued)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Claimant Person (in respect of whom the claim is made)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship to the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID/s","options":[],"required":null,"pdf_field":""},{"help":"Include country code if applicable","type":"phone","label":"Contact Numbers (INDIA)","options":[],"required":null,"pdf_field":""},{"help":"Include country code","type":"phone","label":"Contact Numbers (Overseas)","options":[],"required":null,"pdf_field":""},{"help":"Full address in India","type":"text","label":"Residential Address (INDIA)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured person"},{"title":"Trip Details","fields":[{"help":"DD / MM / YYYY","type":"date","label":"Date of Departure","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Date of Arrival","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured person"},{"title":"Claim Type Selection","fields":[{"help":"Tick all applicable claim types","type":"checkbox","label":"Claim in Respect of following section (please tick against the applicable claim type)","options":["Medical Expense","Baggage Loss","Repatriation of Remains","Baggage Delay","Emergency Medical Evacuation","Compassionate Visit","Daily Allowance in case of Hospitalization","Financial Emergency","Emergency Sickness Dental Relief","Balance Period of Policy","Accidental Death","Permanent Total Disability","Hijack Distress","Accidental Death (Common Carrier)","Allowance Trip Delay","Accidental Death (Air Travel Only)","Trip Cancellation","Trip Curtailment","Golfers Hole in one Celebration","Missed Connection","Burglary (Home Contents)","Loss of Passport","Child Escort","Personal Liability"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Expense Coverage, Emergency Dental Relief, Emergency Medical Evacuation","fields":[{"help":"Hospital where treatment was received","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Doctor who treated the patient","type":"text","label":"Name of Treating Doctor and Contact details","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and treatment received","type":"text","label":"Details of illness & Treatment","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Date of First Symptom","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Please confirm if the illness was also treated in past (Pre-Existing)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify start and end dates DD / MM / YYYY","type":"date","label":"Treatment / Hospitalization dates for any illness / disease in past: From / To","options":[],"required":null,"pdf_field":""},{"help":"Details of past treatments or surgeries","type":"text","label":"Treatment or surgery details of any past illness/ailment","options":[],"required":null,"pdf_field":""},{"help":"List regular medicines","type":"text","label":"Name of medicines you are routinely taking","options":[],"required":null,"pdf_field":""},{"help":"Specify Yes or No for each disease and duration in years/months/days","type":"table","label":"Past History Of Any Chronic Illness With Duration (Disease / Ailment and Duration)","options":[],"required":null,"pdf_field":""},{"help":"Family doctor in India","type":"text","label":"Name of Family Physician (INDIA)","options":[],"required":null,"pdf_field":""},{"help":"Email and phone number","type":"text","label":"Email ID and contact details of Family Physician (INDIA)","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for evacuation","type":"text","label":"If Claiming for Medical Evacuation / Compassionate visit then specify reasons for Medical Evacuation","options":[],"required":null,"pdf_field":""},{"help":"Place from where evacuation is requested","type":"text","label":"Evacuation Request Place From","options":[],"required":null,"pdf_field":""},{"help":"Place to where evacuation is requested","type":"text","label":"Evacuation Request Place To","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Date of Medical Evacuation required","options":[],"required":null,"pdf_field":""},{"help":"Location where death occurred","type":"text","label":"Place of Death","options":[],"required":null,"pdf_field":""},{"help":"Specify places for transportation","type":"text","label":"Medical Transportation from / to","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Date of Death / Medical Transportation","options":[],"required":null,"pdf_field":""},{"help":"List each expense with details and amount","type":"table","label":"Details of expenses incurred – under medical expenses (Item no, Details, Amount)","options":[],"required":null,"pdf_field":""},{"help":"Sum of all expenses claimed","type":"amount","label":"TOTAL CLAIMED AMOUNT *Kindly specify this total claimed amount","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Financial Emergency Assistance","fields":[{"help":"DD / MM / YYYY","type":"date","label":"Date on which fund was lost","options":[],"required":null,"pdf_field":""},{"help":"Explain circumstances of loss","type":"text","label":"Details of incident of loss of fund i.e. how, when, where","options":[],"required":null,"pdf_field":""},{"help":"Name of local contact","type":"text","label":"Local contact Person (INDIA) who can provide payment security","options":[],"required":null,"pdf_field":""},{"help":"Phone number of local contact","type":"phone","label":"Contact Number/s","options":[],"required":null,"pdf_field":""},{"help":"Police station where FIR was filed","type":"text","label":"Name of the Police Station","options":[],"required":null,"pdf_field":""},{"help":"FIR number","type":"text","label":"Police Information (FIR) No","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Loss of Passport, Loss of Baggage; Delay In Checked In Baggage, Trip Delay / Curtailment","fields":[{"help":"Date and time (AM/PM)","type":"date","label":"Date & Time of actual arrival","options":[],"required":null,"pdf_field":""},{"help":"Date and time (AM/PM)","type":"date","label":"Date & Time of scheduled arrival","options":[],"required":null,"pdf_field":""},{"help":"Date and time (AM/PM)","type":"date","label":"Date & Time of Retrieval of Baggage","options":[],"required":null,"pdf_field":""},{"help":"Number of hours baggage was delayed","type":"number","label":"Total Hours of Delay","options":[],"required":null,"pdf_field":""},{"help":"Explain incident details","type":"text","label":"Details of Incident i.e. how, when, where","options":[],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Date on which baggage/passport was lost","options":[],"required":null,"pdf_field":""},{"help":"Location of loss","type":"text","label":"Place where baggage/passport was lost","options":[],"required":null,"pdf_field":""},{"help":"List each expense with details and amount","type":"table","label":"Details of expenses incurred – under travel inconvenience (Item no, Details, Amount)","options":[],"required":null,"pdf_field":""},{"help":"Sum of all expenses claimed","type":"amount","label":"TOTAL CLAIMED AMOUNT *Kindly specify this total claimed amount","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Personal Accident Death / Disability Insurance","fields":[{"help":"Tick one and specify disability details if applicable","type":"choice","label":"Claiming for Personal Accident resulting into DEATH / DISABILITY (exact details of Disability)","options":["DEATH","DISABILITY"],"required":null,"pdf_field":""},{"help":"DD / MM / YYYY","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed for accident","type":"amount","label":"Claimed Amount","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Details & Circumstances of Accident i.e. how, when, where","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person under the influence of alcohol / drugs / medicines at the time of accident","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Police station name","type":"text","label":"Name of the Police Station informed about accident","options":[],"required":null,"pdf_field":""},{"help":"FIR number","type":"text","label":"Police Information (FIR) No.","options":[],"required":null,"pdf_field":""},{"help":"Hospital where treatment was given","type":"text","label":"Name & Address of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Doctor who attended casualty","type":"text","label":"Name & Address of Casualty Doctor","options":[],"required":null,"pdf_field":""},{"help":"Regular doctor in India","type":"text","label":"Name & address of Insured’s Regular physician in India","options":[],"required":null,"pdf_field":""},{"help":"Nominee information","type":"text","label":"Nominee Name, Address & Contact Details","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Authorization for Transfer of Claim Amount by National Electronic Fund Transfer","fields":[{"help":"Name of bank for NEFT payment","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Bank branch details","type":"text","label":"Branch Name & Address","options":[],"required":null,"pdf_field":""},{"help":"Bank branch phone number","type":"phone","label":"Branch Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Account holder name","type":"text","label":"Name of Proposer (As per Bank A/c)","options":[],"required":null,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relation with Insured","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No. (as appearing in Cheque Book)","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"Branch IFSC Code for NEFT","options":[],"required":null,"pdf_field":""},{"help":"MICR code of bank branch","type":"text","label":"Branch MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Savings","Current","Cash / Credit"],"required":null,"pdf_field":""},{"help":"Phone number for contact","type":"phone","label":"Contact numbers in India","options":[],"required":null,"pdf_field":""},{"help":"Alternate email address","type":"email","label":"Alternate Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":["Failure to intimate your claim within 24 hours to our Assistance Company shall invalidate your claim."],"applies_to":"Claims under Saral Suraksha Bima policy including medical care, travel inconvenience, personal accident, special care, legal liability and related coverages.","attachments":["Original bills, receipts, credit card slips or bank statement","Treating Doctor’s certificate for the necessity of an attendant/ evacuation (if applicable)","Attending Physician's Statement/ Civil Surgeon Certificate as per standard format (for Personal Accident claims)","Scanned image of a blank, duly cancelled cheque of your bank (for NEFT payment)"],"declarations":["I hereby declare that the particulars given above are correct and complete.","If any transaction is delayed or not effected due to incomplete or incorrect information, the company is not responsible.","I undertake to advise any change in the particulars of my account for credit of claim amount through NEFT.","I authorize the insurance company and its representatives to collect my medical records from treating doctors or hospitals.","I warrant the truth of the above details to the best of my knowledge and belief.","If any false or fraudulent declarations are made or material facts are concealed, the policy shall be void and all rights forfeited."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"GCIcare@generalicentral.com","label":"Claim Intimation Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"ses.\nCLAIM FORM\nYou can\nclick here\nand check our claim form\nCALL ON\n1800 220233\n1860 500 3333\n022 6783 7800\nEMAIL US AT\nGCIcare@generalicentral.com\nVISIT OUR BRANCH\nYou can check for your nearest branch\nhere\nClaim Process Simplified\nSimple steps to help you file a cl","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"GCIClaims@generalicentral.com","label":"Other Claim Intimation Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/other-claim-process","quote":"NLINE CLAIM INTIMATION\nYou can\nclick here\nto intimate claim\nCALL ON\n1800 220233\n1860 500 3333\n022 6783 7800\nEMAIL US AT\nGCIClaims@generalicentral.com\nVISIT OUR BRANCH\nYou can check for your nearest branch\nhere\nInitiate Quick Claim\nExtended Warranty\nMarine & Others\nProd","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 220 233","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"aim under your insurance policy.\nCashless Claim Process\nReimbursement Claim Process\n1\nIntimate us online or  Call us on 1800 220 233\n2\nSurveyor will inspect the vehicle.\n3\nProvide requested documents to surveyor\n4\nApproved claim amount will be communic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1860 500 3333","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"Motor Claim Process | Generali Central\nGrievance Redressal\nQuick Pay\nNeed Analysis\n1860 500 3333\n|\n022 6783 7800\n1860 500 3333\n022 6783 7800\nProducts\nRenew\nClaim\nHelp & Support\nAbout Us\nTrending Searches\nHealth Insur","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 6783 7800","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"Motor Claim Process | Generali Central\nGrievance Redressal\nQuick Pay\nNeed Analysis\n1860 500 3333\n|\n022 6783 7800\n1860 500 3333\n022 6783 7800\nProducts\nRenew\nClaim\nHelp & Support\nAbout Us\nTrending Searches\nHealth Insurance\nDog Insuran","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/generali-central-insurance/140-claim-form"}