{"id":2340,"title":"SBI General Arogya Gold Claim Form","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/11_0_SBI_General_Arogya_Gold_Group_Claim_Form_549f1fca88.pdf","sha256":"e56a0303f6d6b49c752a3ad99c101d064ed0ce635f0669dafae60aca5b457c64","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to file a health insurance claim under the SBI General Arogya Gold policy.","notes":["Use original bills and receipts only; photocopies of cancelled cheque are not accepted.","Attach a cancelled cheque for bank account details unless premium is paid by cheque from same account.","The form must be signed and dated by the insured or claimant.","For medico legal cases, attach MLC report and police FIR.","The company may seek additional documents or information as necessary for claim processing.","Use block letters to fill the form.","Attach all relevant documents as per the checklist for the type of claim."],"title":"SBI General Arogya Gold Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured/Claimant","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of the claimant","type":"text","label":"Name of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the insured person","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to the insured","type":"text","label":"Relationship with Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Designation (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth of Insured","options":[],"required":true,"pdf_field":""},{"help":"Select gender of the insured","type":"choice","label":"Gender         Male           Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Employee No.","options":[],"required":false,"pdf_field":""},{"help":"Include Mobile, Phone No., E-mail Id","type":"text","label":"Contact Details","options":[],"required":null,"pdf_field":""},{"help":"Include Plot No/Door No., Building Name, Road, Area, City, District, State, Pincode","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end date of insurance period in DD/MM/YYYY format","type":"date","label":"Period of Insurance   From                                                                  To","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Details of Other Insurance","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Is the Accident/Incidence covered under any other Insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide insurer name, policy number, issuance office location, sum insured","type":"text","label":"If 'Yes', specify details and attach a copy of the policy","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Declaration by the Insured","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Payee Details","fields":[{"help":"Name of bank for claim payment","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Branch of the bank","type":"text","label":"Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Account number for payment","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"MICR number of the bank branch","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 person or claimant"},{"title":"Hospitalization Details","fields":[{"help":"Full hospital name","type":"text","label":"Name of Hospital where Admitted","options":[],"required":true,"pdf_field":""},{"help":"Select room category","type":"choice","label":"Room Category occupied","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":true,"pdf_field":""},{"help":"Select reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Injury","Illness","Maternity"],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre-hospitalization Expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses","options":[],"required":true,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post-hospitalization Expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health-Check up Cost","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance charges (Road)","options":[],"required":false,"pdf_field":""},{"help":"Specify other expenses if any","type":"amount","label":"Others","options":[],"required":false,"pdf_field":""},{"help":"Number of days before hospitalization","type":"number","label":"Pre-hospitalization period (days)","options":[],"required":false,"pdf_field":""},{"help":"Number of days after hospitalization","type":"number","label":"Post-hospitalization period (days)","options":[],"required":false,"pdf_field":""},{"help":"Total claimed amount","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""},{"help":"Specify system of medicine (e.g. Allopathy, Ayurveda)","type":"text","label":"System of Medicine","options":[],"required":false,"pdf_field":""},{"help":"Select cause if injury","type":"choice","label":"If Injury give cause","options":["Self inflicted","Road Traffic Accident","Substance Abuse / Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Indicate if case is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if reported to police","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if reports attached","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Claim Documents Submitted - Check List","fields":[{"help":"Tick if attached","type":"checkbox","label":"Copy of the claim intimation, if any","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Hospital Discharge Summary","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"ECG","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Doctor's Prescriptions","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Hospital Break-up Bill","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Pharmacy Bill","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Doctor's request for investigation","options":[],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Others","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Annexure II (Personal Accident Cover): Information to Police Authority","fields":[{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Accident/Incidence","options":[],"required":false,"pdf_field":""},{"help":"Enter time and AM/PM","type":"text","label":"Time of Loss","options":[],"required":false,"pdf_field":""},{"help":"Describe cause","type":"text","label":"Cause of Accident/Incidence","options":[],"required":false,"pdf_field":""},{"help":"Describe details","type":"text","label":"Details of Accident/Incidence","options":[],"required":false,"pdf_field":""},{"help":"Full address of accident location","type":"text","label":"Accident/Incidence Location Address","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Were there any witness to the Accident/Incidence?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is Witness relative of Claimant?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the loss been reported to Police Authority?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Explain reason","type":"text","label":"If 'No', reason for not reporting","options":[],"required":false,"pdf_field":""},{"help":"FIR number if reported","type":"text","label":"First Information Report No","options":[],"required":false,"pdf_field":""},{"help":"MLC number if applicable","type":"text","label":"Medico Legal Case (MLC) No.","options":[],"required":false,"pdf_field":""},{"help":"Date of report","type":"date","label":"Report Date","options":[],"required":false,"pdf_field":""},{"help":"Police station address","type":"text","label":"Address of Police Station","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Was the person moved to hospital immediately after the accident?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Hospital name if moved","type":"text","label":"Name of Hospital","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Annexure II (Personal Accident Cover): To be completed by Nominee in the event of Insured's Death","fields":[{"help":"Full name of nominee","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relationship with Insured","options":[],"required":true,"pdf_field":""},{"help":"Provide guardian name, relationship, designation","type":"text","label":"If nominee is minor, kindly provide the Legal Guardian details","options":[],"required":false,"pdf_field":""},{"help":"Include address, phone, mobile, email","type":"text","label":"Contact Details","options":[],"required":false,"pdf_field":""}],"filled_by":"nominee"},{"title":"Annexure II (Personal Accident Cover): To be filled by treating Doctor","fields":[{"help":"Doctor to sign","type":"signature","label":"Signature of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Annexure III (Cancer & Cardiac Care)","fields":[{"help":"Doctor to sign","type":"signature","label":"Signature of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of last visit","options":[],"required":true,"pdf_field":""},{"help":"Specify frequency","type":"text","label":"Frequency of visits (Weekly/Monthly/Other)","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you ever had the similar condition in past","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"health insurance claims under SBI General Arogya Gold policy","attachments":["Cancelled cheque pertaining to bank account","Copy of other insurance policy if applicable","Copy of the claim intimation, if any","Hospital Discharge Summary","ECG","Doctor's Prescriptions","Hospital Break-up Bill","Pharmacy Bill","Doctor's request for investigation","MLC Report & Police FIR if applicable","Claim Form duly signed","Hospital Bill Payment Receipt","Operation Theatre Notes","Investigation Reports (Including CT/MRI/USG/HPE)","Police Copy","Copy of FIR / Spot Panchnama / Inquest Panchnama","Death Certificate","Death Summary","Post Mortem Report","Original Legal Heir Certificate (if nomination not filed)","Photograph of injured with reflecting disablement","Disability Certificate from Government Authority","Medical Certificate from treating Doctor","Leave Certificate from Employer","Treatment Papers","Study Certificate for Child Education benefit","Original Bills and payment receipts for Adaptation Allowance","Prescription for Adaptation","Original Invoice of Funeral Expenses","Original Ambulance bills and payment receipts","Letter from Medical Practitioner for ambulance need","X Ray and radiological imaging reports for Broken Bones","Certificate from Treating Medical Practitioner for injury details","Appointment Letter","Latest Salary Revision copy","Last 3 Months Salary Slip","Form 16","Employer contact details","Age proof of Insured (Aadhar, Election ID, PAN, School Leaving)","Form 26AS showing tax deducted at source","Income tax return for relevant financial year","Self-declaration","Certificate from Employer confirming employment status for Loss of Income","Certified copy of first hospital consultation and diagnostic report for Cancer Care"],"declarations":["Information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements or concealment of material facts will forfeit claim reimbursement rights.","Consent and authorize TPA/insurance company to seek medical information from hospitals or doctors.","All bills/receipts for this claim are included and no supplementary claims except pre/post-hospitalization claims will be made.","Acceptance of claim amount is full discharge of insurer's obligations under the policy.","The claimant will indemnify insurer against claims made by others under this policy."],"dropped_labels":13},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customer.care@sbigeneral.in","label":"Motor Claims Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"m\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journeys, always\nDownload SBIG App\nRegister or Tra","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"sbig.health@sbigeneral.in","label":"Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"ailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th Floor, Westport, Pan Card","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcitizen.health@sbigeneral.in","label":"Senior Citizen Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 1111","label":"Motor Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"e Claim\nFAQs\nDownload Claim Form\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journ","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 3366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"e simple click\nCheck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 6366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"heck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"sms","value":"561612","label":"Health Claims SMS 'HEALTHCLAIM'","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"y Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office","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/sbi-general-insurance/2340-sbi-general-arogya-gold-claim-form"}