{"id":2366,"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/TravelInsuranceClaimForm.pdf","sha256":"48eac27be650a60b4dfb965a01bb636afba4a2e635f8810c9c3aa33d6c932074","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured policyholder or their authorized representative to claim travel insurance benefits for various covered events such as accidents, medical emergencies, baggage loss, or trip delays.","notes":["Please attach all bills, receipts, credit card slips pertaining to your claim.","Contact the 24 hour helpline before claiming for Medical Accident & Sickness Claims.","Complete the appropriate section of the claim form and read instructions carefully.","Sign the declaration before submitting the form.","Attach claim check if baggage was checked at time of loss or damage.","Attach bills of sale, receipts, or estimates for lost or damaged property.","Use separate sheets if more space is needed 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":"Start date of policy coverage","type":"date","label":"Period From:","options":[],"required":null,"pdf_field":""},{"help":"End date of policy coverage","type":"date","label":"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 the insured's gender","type":"choice","label":"Sex: Male Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Current residential address of the insured","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 of the insured","type":"email","label":"E-mail Id:","options":[],"required":null,"pdf_field":""},{"help":"Permanent residential address of the insured","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 details if other insurance policies exist","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":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Sum insured or coverage amount","type":"amount","label":"Amount (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Start date of the trip","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 the insured","type":"text","label":"Passport No.","options":[],"required":null,"pdf_field":""},{"help":"Destination of the trip","type":"text","label":"Trip Destination:","options":[],"required":null,"pdf_field":""},{"help":"Claim reference number if any","type":"text","label":"Claim Reference No.","options":[],"required":null,"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":"Address of claimant","type":"text","label":"Claimant’s Address:","options":[],"required":null,"pdf_field":""},{"help":"Residential phone number of claimant","type":"phone","label":"Phone No. (Res)","options":[],"required":null,"pdf_field":""},{"help":"Office phone number of claimant","type":"phone","label":"Phone No. (off)","options":[],"required":null,"pdf_field":""},{"help":"Role or relation to insured","type":"text","label":"In what capacity are you making the claim?","options":[],"required":null,"pdf_field":""},{"help":"Select 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","fields":[{"help":"Name of person 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":null,"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":"Description of 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, and 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","type":"text","label":"If yes, please provide the name, address and telephone number of all investigating officers & agencies?","options":[],"required":null,"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 occurred","type":"date","label":"Date of Sickness/Injury","options":[],"required":null,"pdf_field":""},{"help":"Location of sickness or injury","type":"text","label":"Place of Sickness/Injury","options":[],"required":null,"pdf_field":""},{"help":"Description of how sickness or injury happened","type":"text","label":"Circumstances of Sickness/Injury?","options":[],"required":null,"pdf_field":""},{"help":"Description of sickness or injury nature","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":null,"pdf_field":""},{"help":"Provide name, street address, city, state, pin code, and 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":null,"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":null,"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":null,"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 partial disability","type":"date","label":"Dates of partial disability: From: To:","options":[],"required":null,"pdf_field":""},{"help":"Date insured resumed 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":null,"pdf_field":""},{"help":"Name of the attending physician","type":"text","label":"Name of attending Physician:","options":[],"required":null,"pdf_field":""},{"help":"Address of attending physician","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Phone number of attending physician","type":"phone","label":"Phone No.:","options":[],"required":null,"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":null,"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 loss/damage/delay","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":"Description of loss or damage","type":"text","label":"Please describe in detail the nature and extent of loss, damage or delay:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if common carrier was involved","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":"Details about the carrier","type":"text","label":"If yes, please complete the following:","options":[],"required":null,"pdf_field":""},{"help":"Name of the carrier","type":"text","label":"Name of carrier:","options":[],"required":null,"pdf_field":""},{"help":"Flight or trip number","type":"text","label":"Flight, trip or tour number:","options":[],"required":null,"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":null,"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":null,"pdf_field":""},{"help":"Declared value if any","type":"text","label":"Was extra evaluation on property declared? If yes, how much","options":[],"required":null,"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":null,"pdf_field":""},{"help":"Attach claim check if baggage was checked","type":"attachment","label":"If yes, please enclose claim check:","options":[],"required":null,"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":null,"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":null,"pdf_field":""},{"help":"Amount paid by carrier","type":"amount","label":"If yes, amount received?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other insurance exists","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":null,"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":null,"pdf_field":""},{"help":"Indicate if claim filed on other insurance","type":"yes-no","label":"Has a claim been filed? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Status of other insurance claim","type":"text","label":"If yes, what is the current status of the claim","options":[],"required":null,"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":null,"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":null,"pdf_field":""},{"help":"Police or authority case number","type":"text","label":"Case#","options":[],"required":null,"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","type":"date","label":"Date of Cancellation (if applicable):","options":[],"required":null,"pdf_field":""},{"help":"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":null,"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":null,"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":null,"pdf_field":""},{"help":"Indicate if claim filed on other insurance","type":"yes-no","label":"Has a claim been filed? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Status of other insurance claim","type":"text","label":"If yes, what is the current status of the claim","options":[],"required":null,"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 claimed items are used for business","type":"text","label":"Are any claims item used in your business, occupation or profession? If yes, identify the item(s) by * above","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Details of the Expenditure Incurred","fields":[{"help":"List expenditures with details and amounts","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":"travel insurance claims including accidental death, permanent disability, emergency medical and dental expenses, hospital cash, baggage loss and delay, trip cancellation/interruption/curtailment, personal liability, and other related claims","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":["Issuance of this claim form is not to be taken as an admission of liability.","Failure to call the Assistance provider on 24-hour helpline for Medical Accident & Sickness Claims may invalidate your claim.","I authorize any insurance company, physician, hospital or other healthcare provider to release information regarding this claim.","I understand this information will be used by Shriram General Insurance or its representatives to evaluate and determine coverage.","I have a right to receive a copy of this authorization upon request.","A photographic or facsimile copy of this authorization is valid as the original.","This authorization shall be valid for the duration of this claim.","Any person who knowingly files a claim containing materially false, incomplete or misleading information may be subject to prosecution for insurance fraud.","The attending physician declares the information provided is true and understands the consequences of insurance fraud."],"dropped_labels":1},"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/2366-travel-insurance-claim-form"}