{"id":225,"title":"SAMPORNA SURAKSHA-SOOKSHMA (MICRO INSURANCE) CLAIM FORM","purpose":"claim","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/rural-insurance/sampoorna-suraksha-sookshma-micro-insurance/claim-forms/sampoorna-suraksha-sookshma-micro-insurance-retail-claim-form.pdf","sha256":"d8229be91b7f6dfd9b5e917d8ccd9c038bded667f2ff455d607ae34b6af6a945","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant or insured person to file a claim under the Sampoorna Suraksha-Sookshma Micro Insurance policy.","notes":["Issue of this claim form is not to be taken as an admission of liability.","If any detail or information is not readily available, do not delay dispatch of this form; such particulars may be sent later.","All original documents will be returned post verification."],"title":"SAMPORNA SURAKSHA-SOOKSHMA (MICRO INSURANCE) CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"General Information","fields":[{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of insurance period","type":"date","label":"Period of Insurance From To","options":[],"required":null,"pdf_field":""},{"help":"Tick one","type":"choice","label":"Type of coverage Individual Group","options":["Individual","Group"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured (in whose name the policy is issued)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Customer ID no.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(a) Name of the claimant person (in respect of whom the claim is made)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(b) Relationship to the Insured","options":[],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"(c) Present completed age","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(d) Occupation","options":[],"required":null,"pdf_field":""},{"help":"Include city, state and pin code","type":"text","label":"(e) Residential Address City State: Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Describe the incident in detail","type":"text","label":"Please give a full description of the event, the time, date, other parties involved, and any other relevant details","options":[],"required":null,"pdf_field":""},{"help":"Provide other insurance details if applicable","type":"text","label":"Do you have any other insurance that may extend to cover your loss? If so, please provide details of the policy and the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable cover","type":"checkbox","label":"Cover under which claim is made (Please Tick and provide the details)","options":["Hospital Cash","Personal Accident","Building and Contents","Burglary and Robbery","Farm Produce","Agricultural Pump set","Cart protection & Liability","Pedal Cycle"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 1: Hospital Cash","fields":[{"help":"Describe illness or injury","type":"text","label":"Nature of disease/ illness contracted or injury suffered or complete diagnosis","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of disease/ illness first detected","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Details of Pre existing disease/ illness with duration of disease/ illness (if any)","options":[],"required":null,"pdf_field":""},{"help":"Provide past medical history if any","type":"text","label":"Past history of disease/ illness with duration of disease/ illness (if any)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(a) Name and address of attending medical practitioner","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(b) Qualification / Degree","options":[],"required":null,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"(c) Registration no","options":[],"required":null,"pdf_field":""},{"help":"Phone number of medical practitioner","type":"phone","label":"(d) Contact No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(a) Name and address of Hospital/ Nursing Home/ Clinic (where patient hospitalized or treatment taken)","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"(b) Registration no of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"(c) Date of admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"(d) Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable options","type":"choice","label":"Nature of the claim (Please indicate by tick mark) (a) Type of Provider Network Non network (b) Type of admission Emergency Planned Day Care","options":["Network","Non network","Emergency","Planned","Day Care"],"required":null,"pdf_field":""},{"help":"Tick documents enclosed","type":"checkbox","label":"In support of the above claim, I enclose following documents in Original (Please indicate by tick mark) (a) Final Hospital Bill with Receipt (b) Discharge certificate/card from the Hospital (c) Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s certificate regarding diagnosis. (d) Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt","options":["Final Hospital Bill with Receipt","Discharge certificate/card from the Hospital","Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s certificate regarding diagnosis","Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 2: Personal Accident","fields":[{"help":"Describe the accident or loss","type":"text","label":"Please give the description of the loss","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details and certificates","type":"text","label":"Please give medical advice or treatment undertaken, and the Doctors certificates in original, if possible","options":[],"required":null,"pdf_field":""},{"help":"Attach if applicable","type":"attachment","label":"Death certificate /Post mortem report ( if required","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 3: Building and Contents","fields":[{"help":"Provide date and time","type":"date","label":"Date of loss & Time of Loss: am/pm","options":[],"required":null,"pdf_field":""},{"help":"Describe loss circumstances and building details","type":"text","label":"Description the circumstances of Loss, how it happened, and what Caused Loss/Damage and details of the building","options":[],"required":null,"pdf_field":""},{"help":"Provide full address","type":"text","label":"Loss Location Address City: State: Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Provide contact details","type":"text","label":"Contact Details of person/s at Loss location Name: Relationship with Insured: Contact Details: Phone No. Mobile No. Email Id:","options":[],"required":null,"pdf_field":""},{"help":"List contents lost or damaged","type":"text","label":"Description of the Contents","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Nature of loss/ cause of loss","options":[],"required":null,"pdf_field":""},{"help":"Describe usage of premises","type":"text","label":"Premises Occupied as","options":[],"required":null,"pdf_field":""},{"help":"Estimate amount of loss","type":"amount","label":"Your estimate of loss/ damage caused:","options":[],"required":null,"pdf_field":""},{"help":"Provide witness details if any","type":"text","label":"Witness Details Were there any witnesses to the loss/accident? Yes/No If Yes, Name as Person/s: Address: City: State: Pin code: Contact Details: Phone No. Mobile No. Email Id:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide authority report details if reported","type":"text","label":"Information to Authority Has the Loss been reported to an Authority? Yes/No If No, Reason for not reporting If Yes, Provide details: Fire/Police/Municipality/Other Name of Authority: Information report No./Authority reference no. Date: Contact Person/s Address: City: State: Pin code: Contact Details: Phone No. Mobile No. Email Id:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide other insurance details if applicable","type":"text","label":"DETAILS OF OTHER INSURANCE Is the loss / damage covered under any other insurance? Yes/No If Yes, specify details and attach a copy of the policy Name of Insurer Address City: State: Pin code: Contact Details Phone No. Mobile No. Email Id: Policy No. Period of Insurance From To Sum Insured (rs.)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide item details, attach extra sheet if needed","type":"text","label":"Please provide details of claim for property destroyed or damaged or lost Item no of the policy? (Please attach separate sheet if required)","options":[],"required":null,"pdf_field":""},{"help":"List previous losses with date, description, amount and insurer","type":"table","label":"Details of Previous Losses Losses during the 3 preceding years Date of loss Claim description and Cause of loss Amount of loss (Rs.) Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional information if desired","type":"text","label":"Details of Other Information Do you wish to provide any other information? □ Yes □No, If “Yes”, specify","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach photos of damage if available","type":"photo","label":"Please submit photographs of loss or physical damage, wherever possible.","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 4: Robbery and Burglary","fields":[{"help":"Describe cause of loss","type":"text","label":"Nature/ cause of loss","options":[],"required":null,"pdf_field":""},{"help":"Describe loss and damage details","type":"text","label":"Description of loss or damage including damage caused to locks if any","options":[],"required":null,"pdf_field":""},{"help":"Tick and provide case number if yes","type":"choice","label":"Was the loss reported to the Police? If Yes, Case No.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Has the perpetrator been apprehended by the Police?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide location details","type":"text","label":"Where was the item lost located before such loss occurred?","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Was the item left unattended?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"If yes, was the same locked or secured, as the case may be?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List items with details","type":"table","label":"Item (please describe in detail) Date Of manufacture Owner No of pieces Destroyed/ damaged/ lost Price paid","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 5: Farm Produce","fields":[{"help":"Provide location details","type":"text","label":"Where was the farm produce kept at the time of the loss?","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Nature/ cause of loss","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Was there any ignitable or flammable substance kept in or around the farm produce at the time of the loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe preventive actions","type":"text","label":"What preventive measures were taken?","options":[],"required":null,"pdf_field":""},{"help":"Describe salvage efforts if any","type":"text","label":"Was an attempt made to salvage the damaged goods? If yes, details of the salvage?","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 6: Agricultural Pumpset","fields":[{"help":"Provide pump set details","type":"text","label":"Year, make & manufacturer of the Pump Set","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Nature/ cause of loss","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Whether electrical or diesel?","options":["Electrical","Diesel"],"required":null,"pdf_field":""},{"help":"Provide location and usage details","type":"text","label":"Where was the Pump Set located and what was it used for, before the loss?","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Was the pump set in good working condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"How old was the pump set?","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 7: Cart Protection & Liability","fields":[{"help":"Provide details of damage and loss","type":"text","label":"Damage to the Cart (a) What was the time and date of the loss? (b) What was the precise nature in which the loss occurred? (c) Were any attempts made to minimize the loss?","options":[],"required":null,"pdf_field":""},{"help":"Provide veterinary certificate and details","type":"text","label":"Death or Permanent Total Disability of the Animal attached to the Cart (a) Original copy of the Veterinary Practioner certifying either death or PTD (b) Were any attempts made to save the Animal","options":[],"required":null,"pdf_field":""},{"help":"Provide accident and medical details, attach certificates","type":"text","label":"Death or Permanent Total Disability of the authorized driver of the Cart (a) What was the nature of the accident? (b) What was the driver doing at the time of the accident? (c) What was the nature of the bodily injury sustained? (d) Was he given any medical treatment, and if so with what results. Please furnish proof of medical treatment undertaken. (e) Death certificate/ Post mortem report (in case of death)","options":[],"required":null,"pdf_field":""},{"help":"Provide details of third party injury and treatment","type":"text","label":"Damages by a third party caused due to the accidental bodily injury or death of such third party (a) What was the nature of the accident? (b) What was the nature of the injuries sustained? (c) Was he given any medical treatment? Please furnish proof of medical treatment undertaken.","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Section 8: Pedal Cycle","fields":[{"help":"Tick applicable","type":"choice","label":"Was the pedal cycle stolen or has there been loss of the accessories?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick and provide case number if yes","type":"choice","label":"Was the loss reported to the Police? If, Yes, Case No.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Has the perpetrator caught by the Police?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide location details","type":"text","label":"Where has been the pedal cycle located before the loss occurred?","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Was the pedal cycle unattended while it was lost?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Was the same securely fastened and/ or locked while it was unattended?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Have you been given notice of any claim or proceeding in regard to accidental death or bodily injury and accidental damage to property arising out of or connected with the pedal cycle?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List pedal cycle details","type":"table","label":"Date of manufacture Owner No. of pieces Destroyed / Damaged/ Lost Price paid","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration and Signature","fields":[{"help":"Read and agree to the declaration","type":"text","label":"Declaration","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured/Claimant","options":[],"required":true,"pdf_field":""},{"help":"Print name","type":"text","label":"Name of Insured/Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured/Claimant"}],"deadlines":[],"applies_to":"Claims under Sampoorna Suraksha-Sookshma Micro Insurance policy for various coverages including Hospital Cash, Personal Accident, Building and Contents, Burglary and Robbery, Farm Produce, Agricultural Pump set, Cart protection & Liability, and Pedal Cycle","attachments":["Final Hospital Bill with Receipt","Discharge certificate/card from the Hospital","Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s certificate regarding diagnosis","Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt","Doctors certificates in original (Personal Accident)","Death certificate /Post mortem report (if required)","Copy of other insurance policy (if applicable)","Photographs of loss or physical damage (wherever possible)","Veterinary Practitioner certificate (for Cart Protection & Liability)","Proof of medical treatment undertaken (where applicable)","Death certificate/ Post mortem report (in case of death)"],"declarations":["The claimant agrees to provide additional information if required.","The claimant warrants the truth of all statements made in the form to the best of their knowledge and belief.","If any false or fraudulent statement or concealment is made, the policy shall be void and rights to recover under it shall be forfeited."],"dropped_labels":1},"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/225-samporna-suraksha-sookshma-micro-insurance-claim-form"}