{"id":2365,"title":"Travel Insurance Claim Form","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/Overseas-Travel-Insurance-Claim-Form.pdf","sha256":"c0ef00e17cca71e31f0ce6e2190e2e1f0a43a15e61105f9ed6923cbd2c496f40","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is for insured policyholders or their authorized representatives to claim benefits under overseas travel insurance policies.","notes":["Issuance of this claim form is not an admission of liability.","Failure to call the 24-hour helpline for Medical Accident & Sickness Claims may invalidate your claim.","Please attach all relevant documents to support your claim.","Complete the appropriate section of the claim form and sign the declaration.","Use separate sheets if more space is required for descriptions."],"title":"Travel Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"POLICY/CERTIFICATE NO","options":[],"required":null,"pdf_field":""},{"help":"Enter policy coverage start and end dates","type":"date","label":"Period From:                                         to:","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of the insured","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Sex:    Male  Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Current residential address","type":"text","label":"Current Address:","options":[],"required":null,"pdf_field":""},{"help":"Residential phone number","type":"phone","label":"Phone No. (Res)","options":[],"required":null,"pdf_field":""},{"help":"Office phone number","type":"phone","label":"Phone No. (Off)","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail Id:","options":[],"required":null,"pdf_field":""},{"help":"Permanent residential address","type":"text","label":"Permanent Address:","options":[],"required":null,"pdf_field":""},{"help":"Permanent residential phone number","type":"phone","label":"Phone No. (Res)","options":[],"required":null,"pdf_field":""},{"help":"Permanent office phone number","type":"phone","label":"Phone No. (Off)","options":[],"required":null,"pdf_field":""},{"help":"Provide other insurance details if applicable","type":"text","label":"Does the insured have any other Health/Accident or Travel Insurance? If yes, please give details below:","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.:","options":[],"required":false,"pdf_field":""},{"help":"Sum insured or coverage amount","type":"amount","label":"Amount (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Start date of travel","type":"date","label":"Date of trip commencement","options":[],"required":null,"pdf_field":""},{"help":"Planned return date","type":"date","label":"Scheduled date of return","options":[],"required":null,"pdf_field":""},{"help":"Passport number of insured","type":"text","label":"Passport No.","options":[],"required":null,"pdf_field":""},{"help":"Travel destination","type":"text","label":"Trip Destination:","options":[],"required":null,"pdf_field":""},{"help":"Claim reference number if any","type":"text","label":"Claim Reference No.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured policyholder or authorized representative"},{"title":"Claimant Information","fields":[{"help":"Name of claimant if different from insured","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of claimant","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relationship with Policyholder","options":[],"required":null,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Claimant’s Address:","options":[],"required":null,"pdf_field":""},{"help":"Claimant residential phone","type":"phone","label":"Phone No. (Res)","options":[],"required":null,"pdf_field":""},{"help":"Claimant office phone","type":"phone","label":"Phone No. (off)","options":[],"required":null,"pdf_field":""},{"help":"State your capacity (e.g. insured, nominee, representative)","type":"text","label":"In what capacity are you making the claim?","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable claim types","type":"checkbox","label":"Please indicate whether the claim is in respect of (Tick Boxes)","options":["Accidental Death","Permanent Disability","Emergency Medical Expenses","Emergency Dental Treatment","Hospital Cash","Baggage Loss","Baggage Delay","Trip Cancellation/Interruption/Curtailment","Personal Liability","Any Other"],"required":null,"pdf_field":""}],"filled_by":"claimant if different from insured"},{"title":"Authorization and Declaration","fields":[{"help":"Consent to release information for claim processing","type":"yes-no","label":"I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge regarding the insured to release any information request regarding this claim and the loss reported.","options":["Yes"],"required":true,"pdf_field":""},{"help":"Name of person or entity authorized to obtain medical records","type":"text","label":"I also authorize _________________ to obtain any medical records or information to process this claim.","options":[],"required":null,"pdf_field":""},{"help":"Signature of claimant or authorized person","type":"signature","label":"SIGNED (Claimant or authorized person)","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"PLACE","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"DATE","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or authorized person"},{"title":"Personal Accident Claim (Claimant’s Statement)","fields":[{"help":"Date when accident occurred","type":"date","label":"Date of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Time of accident","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of accident circumstances","type":"text","label":"Please describe in detail the circumstance of accident (attach separate sheet if required)","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries sustained","type":"text","label":"Please describe the nature of insured’s injuries:","options":[],"required":null,"pdf_field":""},{"help":"Provide name, street address, city, state, pin code, phone number for each physician/hospital","type":"table","label":"Please list the names & addresses of all treating physicians & hospitals:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if authorities investigated","type":"yes-no","label":"Did police or other authorities investigate the accident? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of investigating officers/agencies if applicable","type":"text","label":"If yes, please provide the name, address and telephone number of all investigating officers & agencies?","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Emergency Medical Expenses / Emergency Dental Expenses (Insured’s Statement)","fields":[{"help":"Name of illness or injury","type":"text","label":"Name of Sickness or Injury","options":[],"required":null,"pdf_field":""},{"help":"Date when sickness or injury started","type":"date","label":"Date of Sickness/Injury","options":[],"required":null,"pdf_field":""},{"help":"Location where sickness or injury occurred","type":"text","label":"Place of Sickness/Injury","options":[],"required":null,"pdf_field":""},{"help":"Describe how sickness or injury happened","type":"text","label":"Circumstances of Sickness/Injury?","options":[],"required":null,"pdf_field":""},{"help":"Describe nature of illness or injury","type":"text","label":"Nature of Sickness/Injury:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if assistance provider was contacted","type":"yes-no","label":"If claim was due to hospitalization was________________ contacted? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain why assistance provider was not contacted","type":"text","label":"If ‘No’, please advice on separate sheet?","options":[],"required":false,"pdf_field":""},{"help":"Provide name, street address, city, state, pin code, phone number for each physician/hospital","type":"table","label":"Please list the names & addresses of all treating physicians & hospitals:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Accidental Injury / Medical Expenses Claim (Attending Physician’s Statement)","fields":[{"help":"Date of accident or sickness","type":"date","label":"Date of Accident/Sickness:","options":[],"required":null,"pdf_field":""},{"help":"Date when treatment started","type":"date","label":"Date of first treatment:","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of injuries","type":"text","label":"Please describe in detail the nature of the Insured’s Injuries","options":[],"required":null,"pdf_field":""},{"help":"Indicate if insured was hospitalized","type":"yes-no","label":"Was the Insured hospitalized? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital details and admission/discharge dates","type":"text","label":"If yes, please list the names & addresses of all hospitals & all admission/ discharge date","options":[],"required":false,"pdf_field":""},{"help":"Indicate if prior injury or illness contributed","type":"yes-no","label":"Did the Insured have any injury or illness prior to the accident that contributed to the accident or to the insured’s present condition? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Description of prior injury or illness","type":"text","label":"If yes, please describe:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if surgery was performed","type":"yes-no","label":"Were any surgical procedures performed? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List surgeries and dates","type":"text","label":"If yes please list all procedures, and dates performed:","options":[],"required":false,"pdf_field":""},{"help":"Symptoms reported by insured","type":"text","label":"What are the insured’s current subjective symptoms?","options":[],"required":null,"pdf_field":""},{"help":"Clinical findings and test results","type":"text","label":"What are the objective findings? (Please include results of current x-rays, lab tests etc.)?","options":[],"required":null,"pdf_field":""},{"help":"Period of total disability","type":"text","label":"Dates of total disability:","options":[],"required":null,"pdf_field":""},{"help":"Period of partial disability","type":"text","label":"Dates of partial disability:","options":[],"required":null,"pdf_field":""},{"help":"Date insured can resume work","type":"date","label":"Date on which insured able to return to work","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other physicians consulted","type":"yes-no","label":"Was the insured seen by any other physician? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other physicians consulted","type":"text","label":"If yes, please list the names and addresses of all other physicians:","options":[],"required":false,"pdf_field":""},{"help":"Name of the attending physician","type":"text","label":"Name of attending Physician:","options":[],"required":true,"pdf_field":""},{"help":"Address of attending physician","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Phone number of attending physician","type":"phone","label":"Phone No.:","options":[],"required":true,"pdf_field":""},{"help":"Signature of attending physician","type":"signature","label":"SIGNED (Attending Physician)","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"attending physician"},{"title":"Baggage Protection / Baggage Delay Claim Information","fields":[{"help":"Date when baggage loss/damage/delay occurred","type":"date","label":"Date of loss, damage or delay","options":[],"required":null,"pdf_field":""},{"help":"Time of incident","type":"text","label":"Time of day  a.m.  p.m.","options":["a.m.","p.m."],"required":null,"pdf_field":""},{"help":"Detailed description of incident","type":"text","label":"Please describe in detail where and how the loss, damage or delay occurred:","options":[],"required":null,"pdf_field":""},{"help":"Describe loss or damage extent","type":"text","label":"Please describe in detail the nature and extent of loss, damage or delay:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if carrier was responsible","type":"yes-no","label":"Was loss, damage or delay occurred while insured property was on or in the custody of a common carrier (e.g., rail road, airline, cruise ship, bus, taxi etc.) Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide carrier details","type":"text","label":"If yes, please complete the following:","options":[],"required":false,"pdf_field":""},{"help":"Name of carrier","type":"text","label":"Name of carrier:","options":[],"required":false,"pdf_field":""},{"help":"Flight or trip number","type":"text","label":"Flight, trip or tour number:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if carrier was notified","type":"yes-no","label":"Was the carrier notified at the time of the loss or damage? Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of notification to carrier","type":"text","label":"If yes, please identify where, when and to whom (name & title) notification was given:","options":[],"required":false,"pdf_field":""},{"help":"Value of extra declared property if any","type":"text","label":"Was extra evaluation on property declared? If yes, how much","options":[],"required":false,"pdf_field":""},{"help":"Indicate if baggage was checked","type":"yes-no","label":"Was baggage checked at the time of loss or damage? Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach claim check if baggage was checked","type":"attachment","label":"If yes, please enclose claim check:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim filed with carrier","type":"yes-no","label":"Has formal claim been filed against the carrier? Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if payment received from carrier","type":"yes-no","label":"If yes, has payment been made to you? Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Amount received from carrier","type":"amount","label":"if yes, amount received?","options":[],"required":false,"pdf_field":""},{"help":"Indicate if other insurance covers loss","type":"yes-no","label":"Do you have any other insurance that may provide coverage for this accident or loss? Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of other insurance policies","type":"text","label":"If yes, please identify name, address and policy number of all other insurance including homeowners, travel club, credit cards etc.:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim filed with other insurer","type":"yes-no","label":"Has a claim been filed?   Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Status of other claim","type":"text","label":"if yes, what is the current status of the claim","options":[],"required":false,"pdf_field":""},{"help":"Indicate if loss reported to authorities","type":"yes-no","label":"Was loss reported to police or other authorities? Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of police or authority report","type":"text","label":"If yes, please identify where, when, and to whom (name & title) loss was reported:","options":[],"required":false,"pdf_field":""},{"help":"Police or case number if applicable","type":"text","label":"Case#","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Flight Delay Claim Information","fields":[{"help":"Name of airline or carrier","type":"text","label":"Name of the Common Carrier:","options":[],"required":null,"pdf_field":""},{"help":"Flight number","type":"text","label":"Flight No.:","options":[],"required":null,"pdf_field":""},{"help":"Departure location","type":"text","label":"From:","options":[],"required":null,"pdf_field":""},{"help":"Arrival location","type":"text","label":"To:","options":[],"required":null,"pdf_field":""},{"help":"Scheduled departure time","type":"text","label":"Schedule Time of Departure","options":[],"required":null,"pdf_field":""},{"help":"Actual departure time","type":"text","label":"Actual time of Departure","options":[],"required":null,"pdf_field":""},{"help":"Date flight was cancelled if applicable","type":"date","label":"Date of Cancellation (if applicable):","options":[],"required":false,"pdf_field":""},{"help":"Explain reason for delay or cancellation","type":"text","label":"Reason of Delay/ Cancellation/ Curtailment:","options":[],"required":null,"pdf_field":""},{"help":"Duration of delay in hours","type":"number","label":"No. of hours delayed:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if connecting flight was missed","type":"yes-no","label":"Did you miss any connecting flight due to above the above delay? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of missed connecting flight","type":"text","label":"If yes, kindly give details:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if other insurance covers delay","type":"yes-no","label":"Do you have any other insurance that may provide coverage for this delay?  Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of other insurance policies","type":"text","label":"If yes, please provide name, address and policy number of all insurance including travel club, credit card etc.)","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim filed with other insurer","type":"yes-no","label":"Has a claim been filed?   Yes  No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Status of other claim","type":"text","label":"if yes, what is the current status of the claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Valuation of Lost and/or Damaged Property","fields":[{"help":"List items lost/damaged with purchase details, costs, and claim amount; attach bills, receipts, or estimates","type":"table","label":"Sr. No., Description, Date & Place of Purchase, Original Cost, Replacement Cost or Estimate, Amount Claimed","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any item is used for business and identify","type":"text","label":"Are any claims item used in your business, occupation or profession? If yes, identify the item(s) by * above","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Details of the Expenditure Incurred","fields":[{"help":"List expenses incurred with details","type":"table","label":"Sr. No., Description of Items, Date, Place, Amount","options":[],"required":null,"pdf_field":""},{"help":"Total amount of expenditure","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"}],"deadlines":[],"applies_to":"Overseas Travel Insurance claims including personal accident, emergency medical expenses, baggage loss/delay, trip cancellation, and related coverages","attachments":["All bills, receipts, credit card slips pertaining to your claim","Claim check if baggage was checked","Bills of sale, receipts, or estimates for lost/damaged property"],"declarations":["I authorize release of any information regarding this claim to Shriram General Insurance or its representatives.","I authorize the named person/entity to obtain medical records to process this claim.","I understand that knowingly submitting false or misleading information may lead to prosecution for insurance fraud.","Attending physician confirms the accuracy of medical information and understands fraud consequences."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"chd@shriramgi.com","label":"Help Desk Email ID for claim intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ase download the CLAIM INTIMATION SHEET, fill it and send it to our Help\n                            Desk via Email ID (chd@shriramgi.com)\nNote:\nPlease ensure that the following information is ready with you at the time of\n                            claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-300-30000","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 4:00 AM to Midnight 12:00","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"Option 1:\nIntimate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-3009","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 9:30 am to 5:30 pm","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our Help","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/shriram-general-insurance/2365-travel-insurance-claim-form"}