{"id":2254,"title":"INDUSIND MOTOR ACCIDENTAL MEDICAL EXPENSES - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-motor-accidental-medical-expenses-claim-form","sha256":"3efce439f0d22ec09ee6fe41e8c58b478e116ef4d1406f85d75746477aa20001","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder or claimant to file a claim for medical expenses arising from a motor accident under the IndusInd Motor Accidental Medical Expenses insurance policy.","notes":["All fields in the form are mandatory.","Fill the form in BLOCK LETTERS.","Attach original documents only.","Use the mobile number provided for claim status and policy renewal contact.","For NEFT payment, attach original cancelled cheque and PAN card copy.","Claim must be intimated immediately to avoid violation of policy conditions.","Keep original documents ready for verification by loss assessor.","The RTGS/NEFT facility will be effective within 15 days of receipt of mandate form.","The customer may discontinue RTGS/NEFT facility by giving 15 days prior written notice.","Claim status can be tracked online, by call center, or SMS.","In case of loss due to riots, inform police immediately.","The claim discharge voucher is not an admission of liability."],"title":"INDUSIND MOTOR ACCIDENTAL MEDICAL EXPENSES - CLAIM FORM","submit":{"to":"IndusInd General Insurance Company Limited Call Centre","how":"Intimate the claim immediately by phone or as per company instructions","address":"Call Centre at 022 4890 3009 (Paid)"},"purpose":"claim","sections":[{"title":"Personal Details of Claimant","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter start date of policy period","type":"date","label":"Policy Period From","options":[],"required":true,"pdf_field":""},{"help":"Enter end date of policy period","type":"date","label":"To","options":[],"required":true,"pdf_field":""},{"help":"Fill in full name in block letters","type":"text","label":"Full Name","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Fill complete address for communication","type":"text","label":"Address for Communication Flat Building Road/Street/Sector Nearest Landmark Area Taluka/Village/District/City Pin Code State","options":[],"required":true,"pdf_field":""},{"help":"Select if you want to update contact details","type":"choice","label":"Change of the contact Details","options":["Yes, I wish to change my contact details","There is no change in my contact details"],"required":true,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No.","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Enter WhatsApp number if different","type":"phone","label":"WhatsApp No.","options":[],"required":false,"pdf_field":""},{"help":"Enter alternate mobile number if any","type":"phone","label":"Alternate Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"D.O.B.","options":[],"required":true,"pdf_field":""},{"help":"Enter Aadhaar number","type":"text","label":"Aadhaar (UIDAI) No.","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""},{"help":"Select your profession","type":"choice","label":"Insured Profession","options":["Private Service","Self Employed","Politician","Retired","Student","Government Service","House Wife"],"required":true,"pdf_field":""},{"help":"Select your monthly income range","type":"choice","label":"Monthly Income","options":["Upto ` 20,000","` 20,001 to ` 50,000","` 50,001 to ` 1,00,000","` 1,00,001 and above"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vehicle Details","fields":[{"help":"Enter vehicle registration number","type":"text","label":"Registration No.","options":[],"required":true,"pdf_field":""},{"help":"Enter chassis number","type":"text","label":"Chassis No.","options":[],"required":true,"pdf_field":""},{"help":"Enter engine number","type":"text","label":"Engine No.","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle make","type":"text","label":"Make","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle model","type":"text","label":"Model","options":[],"required":true,"pdf_field":""},{"help":"Select vehicle class","type":"choice","label":"Class of Vehicle","options":["Two Wheeler","Private Car"],"required":true,"pdf_field":""},{"help":"Enter EV battery serial number if applicable","type":"text","label":"EV Battery Serial No.","options":[],"required":false,"pdf_field":""},{"help":"Enter motor serial number if applicable","type":"text","label":"Motor Serial No.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Motor Own Damage Policy Details","fields":[{"help":"Enter claim number if any","type":"text","label":"Comprehensive/ Own Damage Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number if any","type":"text","label":"Comprehensive/ Own Damage Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Enter insurer's name if applicable","type":"text","label":"Comprehensive/ Own Damage Policy Insurer’s name","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Accident","fields":[{"help":"Enter date of accident","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter time of accident (HH/MM am/pm)","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle speed at time of accident","type":"text","label":"Vehicle Speed","options":[],"required":false,"pdf_field":""},{"help":"Enter location of accident","type":"text","label":"Place of accident","options":[],"required":true,"pdf_field":""},{"help":"Enter garage name if vehicle was taken there","type":"text","label":"Name of Garage","options":[],"required":false,"pdf_field":""},{"help":"Enter number of passengers excluding driver","type":"number","label":"No. of persons traveling at the time of accident excluding driver","options":[],"required":true,"pdf_field":""},{"help":"Describe the accident in detail","type":"text","label":"Description of the accident (Please attach a separate sheet if needed)","options":[],"required":true,"pdf_field":""},{"help":"Select purpose of vehicle use","type":"choice","label":"For what purpose was the vehicle being used at the time of accident?","options":["Personal","For Hire of Passenger","Carriage of Goods"],"required":true,"pdf_field":""},{"help":"Enter origin and destination","type":"text","label":"Vehicle was plying from to","options":[],"required":false,"pdf_field":""},{"help":"Select type of claim","type":"choice","label":"Type of Claim","options":["Accidental Medical Hospitalization","Emergency Road Ambulance","Post Hospitalization","Accidental Medical OPD","Doctor Referral","Hospital Cash Cover"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Driver at Time of Accident","fields":[{"help":"Enter driver's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter driver's address","type":"text","label":"Correspondence Address","options":[],"required":true,"pdf_field":""},{"help":"Enter driver's phone number","type":"phone","label":"Telephone Number","options":[],"required":false,"pdf_field":""},{"help":"Select driver's gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter driver's date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter driver's license number","type":"text","label":"License No.","options":[],"required":true,"pdf_field":""},{"help":"Enter licensing authority","type":"text","label":"Licensing Authority","options":[],"required":true,"pdf_field":""},{"help":"Enter license validity date","type":"date","label":"Valid upto","options":[],"required":true,"pdf_field":""},{"help":"Select driver type and specify if other","type":"choice","label":"Is the Driver","options":["Owner","Paid Driver","Any Other Person, please specify"],"required":true,"pdf_field":""},{"help":"Indicate if driver was under influence","type":"yes-no","label":"Was the driver under the influence of alcohol","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select license type","type":"choice","label":"Type of Licence","options":["Permanent","Learner"],"required":true,"pdf_field":""},{"help":"Indicate if driver had other accidents recently","type":"yes-no","label":"Driver involve in any other accident in last two years","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of other accidents if any","type":"text","label":"If yes, please provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Pillion Rider at the Time of Accident","fields":[{"help":"Enter pillion rider's name if applicable","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Enter pillion rider's address","type":"text","label":"Correspondence Address","options":[],"required":false,"pdf_field":""},{"help":"Enter pillion rider's phone number","type":"phone","label":"Telephone Number","options":[],"required":false,"pdf_field":""},{"help":"Select pillion rider's gender","type":"choice","label":"Gender","options":["Male","Female"],"required":false,"pdf_field":""},{"help":"Enter pillion rider's date of birth","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Indicate if driver was under influence","type":"yes-no","label":"Was the driver under the influence of alcohol","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide reference number if driver was under influence","type":"text","label":"If Yes, please provide the reference number","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claim Details","fields":[{"help":"Select the claim cover type","type":"choice","label":"Type of Claim (Select the appropriate Cover which is being claimed)","options":["Accidental Medical Hospitalization","Doctor Referral","Emergency Road Ambulance","Post Hospitalization","Accidental Medical OPD","Hospital Cash Cover"],"required":true,"pdf_field":""},{"help":"Indicate if emergency assistance was informed","type":"yes-no","label":"Has he Emergency Assistance Service Provider been intimated?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide emergency assistance reference number","type":"text","label":"If Yes, please provide the reference number","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Enter hospital admission date","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital discharge date","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Describe injuries sustained","type":"text","label":"Details of Injury Suffered","options":[],"required":true,"pdf_field":""},{"help":"Enter date injury was sustained","type":"date","label":"Date of Injury sustained","options":[],"required":true,"pdf_field":""},{"help":"Enter ABHA number if available","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA address if available","type":"text","label":"ABHA Address","options":[],"required":false,"pdf_field":""},{"help":"Fill hospital details","type":"text","label":"Details of Hospital in which treatment was taken: Name of the Hospital Address of Hospital City PIN Code State Telephone No. / Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Enter treating doctor's name","type":"text","label":"Name of Treating Physician / Surgeon","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Provide details for each bill head: Room Rent & Nursing Charges, Doctor / Consultation fees, Investigation Charges, Surgeon and Assistant Surgeon Charges, Anthesis Charges, Operation theatre Charges, Medicine Charges (Includes Ward, OT, Consumables etc.), Miscellaneous Charges (Admission/Registration etc.), Post Hospitalisation Bills (if any), Taxes/Service Tax/Surcharge. For each, provide amount, bill number, bill date, and indicate if bill is attached (Yes/No).","type":"table","label":"Bill Heads, Amount, Bill Number, Bill Date, Bills Attached","options":[],"required":true,"pdf_field":""},{"help":"Enter total amount claimed","type":"amount","label":"Total Claimed Amount","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Documents Enclosed","fields":[{"help":"Indicate if claim form is attached","type":"yes-no","label":"Claim Form Dully filled","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if investigation reports are attached","type":"yes-no","label":"Investigation Reports","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if authorization form is attached","type":"yes-no","label":"Authorisation Form","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if medicine/pharmacy bills with prescription are attached","type":"yes-no","label":"Medicine/Pharmacy Bills with Doctors Prescription","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if discharge summary is attached","type":"yes-no","label":"Discharge Summary","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if hospital bills are attached","type":"yes-no","label":"Hospital Bills","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if hospital payment receipt is attached","type":"yes-no","label":"Hospital Payment receipt","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if indoor case papers are attached","type":"yes-no","label":"Indoor Case Papers (duplicate Copy)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if photo identity proof is attached","type":"yes-no","label":"Photo Identity Proof","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if other documents requested by company are attached","type":"yes-no","label":"Others (as requested by Company)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"To be filled by Treating Doctor","fields":[{"help":"Enter date of first consultation","type":"date","label":"Date of First Consultation (Prior to Hospitalisation)","options":[],"required":true,"pdf_field":""},{"help":"Describe patient's complaint at admission","type":"text","label":"With what Complaint the patient was admitted for","options":[],"required":true,"pdf_field":""},{"help":"Describe injuries suffered","type":"text","label":"Details of Injury Suffered","options":[],"required":true,"pdf_field":""},{"help":"Describe surgery or treatment given","type":"text","label":"Nature of Surgery / treatment given","options":[],"required":true,"pdf_field":""},{"help":"Enter number of in-patient beds including ICU","type":"number","label":"Number of in-patient beds in the hospital (including ICU)","options":[],"required":true,"pdf_field":""},{"help":"Date of doctor's signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Doctor to sign and seal","type":"signature","label":"Doctor's Seal & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Bank Details for NEFT Payment (For Reimbursement Claims)","fields":[{"help":"Enter bank account holder's full name","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account","options":["Saving","Current"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter 9 digit MICR code from cheque","type":"text","label":"MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)","options":[],"required":true,"pdf_field":""},{"help":"Enter 11 character IFSC code from cheque","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"Confirm understanding of electronic payment","type":"checkbox","label":"I understand that anyny refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":["Intimate the claim to the insurance company immediately. Delay in intimation would tantamount to a violation of policy condition."],"applies_to":"IndusInd Motor Accidental Medical Expenses insurance policy claims","attachments":["Original cancelled cheque","Copy of PAN card","Claim Form Dully filled","Investigation Reports","Authorisation Form","Medicine/Pharmacy Bills with Doctors Prescription","Discharge Summary","Hospital Bills","Hospital Payment receipt","Indoor Case Papers (duplicate Copy)","Photo Identity Proof","Others (as requested by Company)"],"declarations":["I declare that the details given above are true and correct to the best of my knowledge.","I agree that if any information is found incorrect, all rights under the policy will be forfeited.","I have read and retained the Claim Procedure attached to this Claim Form.","I agree to provide additional information if required.","I will indemnify the company for any loss arising out of misstatement in this form.","I understand that any refund or payment will be credited only through electronic mode to my bank account.","I undertake to refund any excess amount credited to my account within 7 days of communication.","I agree that claim payment will be credited from the date the company gets confirmation from its bankers.","Issuance of this form does not imply acceptance of liability.","The company reserves the right to have the insured examined by a doctor appointed by it for verification.","As per IRDAI, PAN card copy is mandatory for claims above 1 lac; photo identity proof is mandatory for claims below 1 lac.","CTS 2010 compliant cancelled cheque or passbook/bank statement copy is mandatory for NEFT settlements."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"services@indusindinsurance.com","label":"Health Insurance Claims Email","level":1,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"nce Claim\nTravel Insurance Claim\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"indusind@europ-assistance.in","label":"Travel Insurance Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance App\nWebsite:\nOnline Claim Intimation\nOffline Visit:\nLocate your nearest branch\nh","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91 22 48903009","label":"Car Insurance Claim Intimation","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934189","label":"Motor Claims Helpline","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"ation.\nNeed Guidance on Car Coverage?\nTalk to Our Professional Advisors\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nSteps to Take After a Car ​Accident\nThe following steps can expedite the road accident insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934188","label":"Health Claims Helpline","level":null,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"your nearest location.\nExpert health advice you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934184","label":"Travel Claims Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"e you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation\nYour claim gets rejected when you don't gi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+912248903009","label":"Inland Travel Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"rds your registered bank account.\nHow to Contact Us For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 552","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"91-22-67347843","label":"International Travel Helpline (abroad)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 209 5522","label":"International Travel Helpline (in India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance","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/indusind-general-insurance/2254-indusind-motor-accidental-medical-expenses-claim-form"}