{"id":2354,"title":"MICRO INSURANCE INSURANCE POLICY Claim Form","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/caa801a55399493fa570db69395877a2.pdf","sha256":"88aac63afd9cff896f76ab5f1abb17d3da7c20e9573b2cf3accbb92486988829","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder or claimant to file a claim under the micro insurance policy with SBI General Insurance Company Ltd.","notes":["Use DD/MM/YYYY format for all dates.","Tick appropriate boxes clearly.","Provide full and accurate details to avoid claim rejection.","Attach all relevant documents as per the checklist.","If nominee is minor, provide legal guardian details.","Issuance of the form does not guarantee claim acceptance."],"title":"MICRO INSURANCE INSURANCE POLICY Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. DETAILS OF INSURED/CLAIMANT","fields":[{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Insured","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender Male Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Fill full address details","type":"text","label":"Address Plot No/Door No. Building Name Road Area City Pincode State","options":[],"required":null,"pdf_field":""},{"help":"Provide phone numbers and email","type":"text","label":"Contact Details Phone No. Mobile E-mail Id","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format for both dates","type":"date","label":"Period of Insurance From To","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"B. FOR WHICH BENEFIT DO YOU CLAIM?","fields":[{"help":"Enter the amount claimed for each selected benefit","type":"amount","label":"Amount Claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"C. DETAILS OF ACCIDENT / ILLNESS","fields":[{"help":"Select whether claim is due to accident or illness","type":"choice","label":"Is claim related to Accident Illness","options":["Accident","Illness"],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Accident/Incidence","options":[],"required":null,"pdf_field":""},{"help":"Provide time and select AM or PM","type":"text","label":"Time of Loss A.M. / P.M.","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"Describe cause of accident or illness","type":"text","label":"Cause of Accident/Incidence","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed description","type":"text","label":"Details of Accident/Incidence","options":[],"required":null,"pdf_field":""},{"help":"Provide full location address","type":"text","label":"Accident/Incidence Location Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Were there any witness to the Accident/Incidence? Yes No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"INFORMATION TO POLICE AUTHORITY","fields":[{"help":"Explain why not reported if applicable","type":"text","label":"If 'No', reason for not reporting","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"First Information Report No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Medico Legal Case (MLC) No.","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Report Date","options":[],"required":null,"pdf_field":""},{"help":"Provide police station contact details","type":"text","label":"Address of Police Station Pincode Contact Details Phone No. Mobile E-mail Id","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospital Details (if person moved to hospital immediately after accident)","fields":[{"help":"","type":"yes-no","label":"Was the person moved to hospital immediately after the accident? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Accident and Injury Details","fields":[{"help":"Name of insured person","type":"text","label":"of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender Male Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Provide date of birth or age","type":"text","label":"Date of Birth / Age","options":[],"required":null,"pdf_field":""},{"help":"Describe nature of accident and injuries","type":"text","label":"Nature of the Accident/Incident and details of injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"Explain cause","type":"text","label":"Cause of Accident/Incident","options":[],"required":null,"pdf_field":""},{"help":"Answer each part accordingly","type":"yes-no","label":"Is death: a) Solely due to Accident/Incident Yes No b) Traceable to any disease Yes No c) Traceable to any previous injury Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If 'Yes', give details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was insured under influence of drugs / intoxicants / alcohol at the time of accident? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the insured suffering from any disease or injury which may have contributed to the accident or likely to aggravate his/her condition? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If 'Yes', give details","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"ANNEXURE I: MEDICAL CERTIFICATE - TO BE FILLED BY TREATING DOCTOR","fields":[{"help":"","type":"text","label":"Name of treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualifications","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Doctor's phone number","type":"text","label":"Contact Details Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"ANNEXURE II: TO BE COMPLETED BY NOMINEE IN THE EVENT OF INSURED’S DEATH","fields":[{"help":"","type":"text","label":"Name of Nominee","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Insured","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Nominee's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Nominee's contact details","type":"text","label":"Contact Details Phone No. Mobile E-mail Id","options":[],"required":null,"pdf_field":""},{"help":"Provide guardian details if nominee is minor","type":"text","label":"If nominee is minor, kindly provide the Legal Guardian details: Name of Guardian Relationship with Insured Date of Birth Address Contact Details Phone No. Mobile E-mail Id","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Nominee's signature","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"nominee"},{"title":"ILLNESS DETAILS","fields":[{"help":"Describe signs and symptoms","type":"text","label":"Signs and symptoms of illness","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"When was the illness first diagnosed/detected?","options":[],"required":null,"pdf_field":""},{"help":"Provide investigation details and results","type":"text","label":"Brief details of Investigation done with the results confirming diagnosis","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever had the similar signs / symptoms / illness in past? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide past illness details if applicable","type":"text","label":"If ‘Yes’, provide details","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Doctor consulted first","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital contact details","type":"text","label":"Contact Details Phone No. Mobile E-mail Id","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format for both dates","type":"date","label":"Date of first visit to Hospital Date of last visit","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time with AM/PM","type":"text","label":"Date & Time of Admission A.M. / P.M.","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Type of Room on the day of admission ICU Non-ICU","options":["ICU","Non-ICU"],"required":null,"pdf_field":""},{"help":"Provide date and time with AM/PM","type":"text","label":"Date & Time of Discharge A.M. / P.M.","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"Provide number of days spent in ICU and Non-ICU","type":"number","label":"No of Days in ICU No of Days in Non-ICU","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification of treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Treating Doctors Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Provide full hospital address","type":"text","label":"Address of the Hospital Plot No/Door No. Building Name Road Area City Pincode State","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital contact details","type":"text","label":"Contact Details Phone No. Mobile E-mail Id","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"D. DETAILS OF PREVIOUS HEALTH CLAIM","fields":[{"help":"","type":"yes-no","label":"Have you incurred any claim before under this contract or under all other health contracts? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of previous claims if any","type":"text","label":"If Yes, please provide details","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"E. DETAILS OF OTHER INSURANCE/INTEREST","fields":[{"help":"","type":"yes-no","label":"Is the Symptoms/Diagnosis/Illness claimed for covered under any other Insurance? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide other insurance details if applicable","type":"text","label":"If 'Yes', specify details and attach a copy of the policy: Name of Insurer Policy Issuance Office Location Policy No. Sum Insured Period of Insurance From To","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"F. DETAILS OF OTHER INFORMATION","fields":[{"help":"","type":"yes-no","label":"Do you wish to provide any other information? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide any additional information","type":"text","label":"If 'Yes', specify","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"G. ENCLOSURES CHECKLIST","fields":[{"help":"","type":"checkbox","label":"Claim Form duly filled & signed","options":["Claim Form duly filled & signed"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital Summary","options":["Hospital Summary"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Doctor's Certificate","options":["Doctor's Certificate"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Investigation Reports","options":["Investigation Reports"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Policy Copy","options":["Policy Copy"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Photo Identity Proof","options":["Photo Identity Proof"],"required":null,"pdf_field":""},{"help":"Specify any other documents attached","type":"text","label":"Any other documents, please specify","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Signature","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Claimant/Insured","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Insured/Claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"}],"deadlines":[],"applies_to":"Micro Insurance Policy claims including Death, PTD, Hospital Cash, Critical Illness, and Asset Insurance benefits","attachments":["Claim Form duly filled & signed","Hospital Summary","Doctor's Certificate","Investigation Reports","Policy Copy","Photo Identity Proof","Any other documents, please specify"],"declarations":["Issuance of this form does not amount to admission of liability or waiver of policy terms.","If any claim is dishonest or fraudulent, the policy shall be void and benefits forfeited.","I/We declare the truth of the particulars and understand false statements will forfeit claim rights.","I/We accept the amount as full discharge of obligations under the policy.","I/We indemnify the insurer against claims by any other person under this policy.","I consent and authorize TPA/insurance company to seek medical information from hospitals or doctors."],"dropped_labels":7},"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/2354-micro-insurance-insurance-policy-claim-form"}