{"id":2357,"title":"CLAIM FORM - WORKMENS COMPENSATION","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/d39c471133554bc48b361b022524a60a.pdf","sha256":"361c0f4668c47055ecbe9ea70d16a13390dc0cf6ddc05b32a3a610bab372935a","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to file a workmen's compensation claim for injuries or death due to an accident at work.","notes":["Issue of this claim form is not to be taken as an admission of liability.","Follow instructions carefully for the statement of earnings to avoid delays.","Attach original bills and required documents as per claim type.","Use clear and legible handwriting."],"title":"CLAIM FORM - WORKMENS COMPENSATION","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. DETAILS OF INSURED/CLAIMANT","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"From and to dates","type":"date","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Full name","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Nature of business or occupation","type":"text","label":"Business/Occupation","options":[],"required":null,"pdf_field":""},{"help":"Start and end dates","type":"date","label":"Period of Insurance From ____/____/_______ to ____/____/_______","options":[],"required":null,"pdf_field":""},{"help":"Policy indemnity limits","type":"text","label":"Limits of Indemnity under the policy","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"B. DETAILS OF ACCIDENT","fields":[{"help":"Select yes or no","type":"yes-no","label":"Were there any witnesses to the Accident and resultant injuries/death ? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Names of witnesses if any","type":"text","label":"Name of Person/s","options":[],"required":null,"pdf_field":""},{"help":"Address of witnesses","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"City of witnesses","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of witnesses","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code of witnesses","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of witnesses","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Has the Accident been reported to an Authority (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of authority reported to","type":"text","label":"Name of Authority","options":[],"required":null,"pdf_field":""},{"help":"Reference number from authority","type":"text","label":"Authority Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Contact person at authority","type":"text","label":"Contact Person/s","options":[],"required":null,"pdf_field":""},{"help":"Address of authority","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"City of authority","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of authority","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code of authority","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of authority","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Date when accident occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Time with AM/PM","type":"text","label":"Time of Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of accident","type":"text","label":"Cause of Accident / Incidence","options":[],"required":null,"pdf_field":""},{"help":"Accident location address line 1","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Accident location address line 2","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of accident location","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of accident location","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code of accident location","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number at accident location","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile number at accident location","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Email at accident location","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"C. DETAILS OF OTHER INSURANCE/INTEREST","fields":[{"help":"Select yes or no","type":"yes-no","label":"Is the Accident/damage covered under any other Insurance (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of other insurer if any","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Address of other insurer","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"City of other insurer","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of other insurer","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code of other insurer","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of other insurer","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other insurer","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Email of other insurer","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"From and to dates of other insurance","type":"date","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"THE INJURED / DECEASED PERSON","fields":[{"help":"Full name and address","type":"text","label":"Name and address of Injured/deceased","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender (Male) (Female)","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Date of birth or age","type":"date","label":"Date of birth / Age","options":[],"required":null,"pdf_field":""},{"help":"Full address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"City","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Occupation or nature of work","type":"text","label":"State occupation / nature of work of the injured person","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Was the Injured/deceased person engaged in this occupation when the accident occurred?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe work if different","type":"text","label":"If “No”, state exactly the nature of the work he/she was doing at the time of accident.","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"If the Injured/deceased person in your direct employment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details if not direct employment","type":"text","label":"If “No”, give details","options":[],"required":null,"pdf_field":""},{"help":"Contractor name if applicable","type":"text","label":"Name of the Contractor","options":[],"required":null,"pdf_field":""},{"help":"Contractor address line 1","type":"text","label":"Address Line 1","options":[],"required":null,"pdf_field":""},{"help":"Contractor address line 2","type":"text","label":"Address Line 2","options":[],"required":null,"pdf_field":""},{"help":"Contractor phone number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Contractor mobile number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Contractor city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Contractor state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Contractor pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Work given to contractor","type":"text","label":"Nature of work entrusted to contractor","options":[],"required":null,"pdf_field":""},{"help":"Date of joining service","type":"date","label":"When did the Injured/deceased person enter your service?","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have the Injured/deceased persons been taken to hospital or medically attended? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"Name of Hospital / Physician","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Hospital address line 1","type":"text","label":"Address Line 1","options":[],"required":null,"pdf_field":""},{"help":"Hospital address line 2","type":"text","label":"Address Line 2","options":[],"required":null,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Hospital mobile number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Hospital city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Hospital state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Hospital pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"D. INJURY DETAILS","fields":[{"help":"Describe injury and body part","type":"text","label":"State nature of injury & part of body affected","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Is there disablement? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select type of disablement","type":"choice","label":"If “Yes” select Total Partial Permanent Temporary","options":["Total","Partial","Permanent","Temporary"],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Is the disability solely caused by this accident / Incident (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain other causes if any","type":"text","label":"If “No”, give details","options":[],"required":null,"pdf_field":""},{"help":"Duration and end date","type":"text","label":"How long is the disablement expected to last? _______ Days Upto ____/_____/___________","options":[],"required":null,"pdf_field":""},{"help":"Percentage of disability","type":"number","label":"Extent of disability","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Is any improvement possible from current disablement? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Expected improvement and treatment","type":"text","label":"If “Yes” specify with % improvement and action required","options":[],"required":null,"pdf_field":""},{"help":"Date and time with AM/PM","type":"text","label":"Time and date when the injured person actually ceased work.","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Was the injured person under the influence of alcohol or drugs at the time of accident? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Current health status","type":"text","label":"Present health condition","options":[],"required":null,"pdf_field":""},{"help":"Additional relevant details","type":"text","label":"Death examination point of Addiction to drugs / alcohol Disposed to Malinger Any other details","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Post Mortem Done (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date post mortem was done","type":"date","label":"Date of PM Done","options":[],"required":null,"pdf_field":""},{"help":"Post mortem number","type":"text","label":"PM No.","options":[],"required":null,"pdf_field":""},{"help":"Hospital name for post mortem","type":"text","label":"Name of Hospital where Post mortem has been done","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of insured/claimant","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print full name","type":"text","label":"Name of Insured/Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"F. TABLE OF WAGES","fields":[{"help":"Fill monthly wages details as per instructions","type":"table","label":"Month and Year, Basic pay and dearness Allowance, Overtime bonus, Concession in value of food – stuffs and others, All others","options":[],"required":null,"pdf_field":""},{"help":"Total earnings amount and period","type":"amount","label":"Total earnings in the period (specify dates)","options":[],"required":null,"pdf_field":""},{"help":"Average monthly wage amount","type":"amount","label":"Average monthly wages","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Were the above stated wages paid, or fallen due for payment, to the injured person? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Was the injured person absent from work at any time, during the above stated period, for 14 or more consecutive days? (Yes) (No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify absence period","type":"text","label":"If “Yes”, period of absence from ____/____/__________ to ____/____/__________","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for absence","type":"text","label":"Reasons for absence","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of insured","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print full name","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":[],"applies_to":"workmen's compensation claims under the policy","attachments":["Claim Bill","Medical Certificate regarding Cause & Duration of Disablement (for Temporary Disablement Claims)","Medical Bills (for Temporary Disablement Claims)","Medical Certificate regarding Disablement (for Permanent Disablement Claims)","Memorandum of Agreement as per W.C Act between Insured and the injured workman (for Permanent Disablement Claims)","Death certificate (for Fatal Claims)","Copy of post Mortem report (for Fatal Claims)","F.I.R / Final Investigation report (for Fatal Claims)","Form A of W.C Act duly completed by the Insured (for Fatal Claims)","Statement of Witnesses, if any (for Fatal Claims)"],"declarations":["The claimant warrants the truth of the statements to the best of their knowledge and belief.","If any false or fraudulent statement or concealment is made, the claim shall be forfeited and the policy null and void."],"dropped_labels":1},"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/2357-claim-form-workmens-compensation"}