{"id":2368,"title":"SHRI SARV CARE BENEFIT HEALTH 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/ff95bea0-4940-4052-be96-c47a6efedfe6_Sarv%20Care%20-%20Claim%20Form%20NEW%20(1).pdf","sha256":"cb576ec1a818ca8b2309a5062b5df5f78980e9df736abdd19dc629da395259b4","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder or claimant to file a health insurance claim under the Shri Sarv-Care Health Benefit Package Policy. It collects details about the insured, illness or accident, hospitalization, and includes declarations by the insured, nominee, treating doctor, and hospital.","notes":["Issuance of this form does not admit liability or waive policy terms.","Fraudulent claims will void the policy and forfeit benefits.","Attach a cancelled cheque for bank account details.","Use original bills and documents as applicable.","Fill dates in DDMMYYYY format.","Attach CKYC form if claim amount exceeds Rs.1 lakh.","Attach FIR/MLC copy where applicable.","Declarations require signatures and dates.","Hospital and treating doctor sections to be filled by respective parties."],"title":"SHRI SARV CARE BENEFIT HEALTH INSURANCE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the Insurance/Claimant","fields":[{"help":"","type":"text","label":"POLICY NUMBER","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"CLAIM NUMBER","options":[],"required":null,"pdf_field":""},{"help":"Enter end date of insurance period","type":"date","label":"Period of Insurance To","options":[],"required":null,"pdf_field":""},{"help":"Enter date when policy was first joined","type":"date","label":"Date of First Joining the Policy","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Patient","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to insured patient","type":"text","label":"Relationship with the Insured","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of insured patient","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select gender of insured patient","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"City of residence","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of residence","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"Contact Details Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Sections Under Which Claiming the Benefit","fields":[{"help":"Tick if claiming this benefit","type":"checkbox","label":"Hospital Daily Cash Benefit","options":["Hospital Daily Cash Benefit"],"required":null,"pdf_field":""},{"help":"Tick if claiming this benefit","type":"checkbox","label":"Criticare Lumpsum Benefit","options":["Criticare Lumpsum Benefit"],"required":null,"pdf_field":""},{"help":"Tick if claiming this benefit","type":"checkbox","label":"Vector Borne Diseases Benefit","options":["Vector Borne Diseases Benefit"],"required":null,"pdf_field":""},{"help":"Tick if claiming this benefit","type":"checkbox","label":"Personal Accident Benefits","options":["Personal Accident Benefits"],"required":null,"pdf_field":""},{"help":"Tick if claiming this benefit","type":"checkbox","label":"Loss of Employment","options":["Loss of Employment"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Insurance History","fields":[{"help":"Select if currently covered by other health insurance","type":"yes-no","label":"Currently covered by any other Mediclaim health insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date when first insurance started without break","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"If Yes, Company Name","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Select if hospitalized in last 4 years","type":"yes-no","label":"Have you been hospitalized in the last four years since inception of the contract","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide date and duration of hospitalization","type":"text","label":"If YES (specify date & duration)","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis details","type":"text","label":"If YES (specify Diagnosis)","options":[],"required":null,"pdf_field":""},{"help":"Select if previously covered by other health insurance","type":"yes-no","label":"Previously covered by any other Mediclaim/Health insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of previous insurance company","type":"text","label":"If Yes, Company Name","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Illness / Accident / Event During Hospitalization","fields":[{"help":"Name of diagnosed illness","type":"text","label":"Diagnosed Illness","options":[],"required":null,"pdf_field":""},{"help":"Describe signs and symptoms","type":"text","label":"Signs & symptoms of Illness","options":[],"required":null,"pdf_field":""},{"help":"Date or time illness was first diagnosed","type":"text","label":"(i) When was the illness first Diagnosed / detected?","options":[],"required":null,"pdf_field":""},{"help":"Date and time of hospital admission","type":"date","label":"(ii) Date & Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Date and time of hospital discharge","type":"date","label":"(iii) Date & Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Doctor who treated the patient","type":"text","label":"Name of Treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"Address of Hospital","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 postal code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Accidental Injury Leading to Hospitalization or Disability or Death","fields":[{"help":"Name of injured or deceased insured person","type":"text","label":"Name of the Insured Person dead/injured in the accident","options":[],"required":null,"pdf_field":""},{"help":"Date when accident occurred","type":"date","label":"Date of accident","options":[],"required":null,"pdf_field":""},{"help":"Select AM or PM and specify place","type":"text","label":"Time and Place accident occurred","options":["AM","PM"],"required":null,"pdf_field":""},{"help":"Describe accident circumstances","type":"text","label":"Please describe in detail the circumstances of accident (attach separate sheet If needed)","options":[],"required":null,"pdf_field":""},{"help":"Select if accident related to occupation","type":"yes-no","label":"Was the accident related to the Insured’s occupation?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain how accident related to occupation","type":"text","label":"If Yes, How?","options":[],"required":null,"pdf_field":""},{"help":"Select if permanent disablement occurred","type":"yes-no","label":"Permanent Disablement?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if temporary disablement occurred","type":"yes-no","label":"Temporary Disablement?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Start date of temporary disablement","type":"date","label":"Period of temporary total disablement From","options":[],"required":null,"pdf_field":""},{"help":"End date of temporary disablement","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Select if any modifications done","type":"yes-no","label":"Any Modification of Residential Accommodation or Vehicle done?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter hospitalization expenses","type":"amount","label":"Expenditure towards Hospitalization for the injury or disability management (in Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Enter transportation expenses for mortal remains","type":"amount","label":"Expenditure towards transportation on of mortal remains (in Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Doctor name at hospital managing injury","type":"text","label":"Details of the Hospital, where the above management is done; Name of Treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Hospital name managing injury","type":"text","label":"Name of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital address managing injury","type":"text","label":"Address of Hospital","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 postal code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of death","type":"text","label":"Please describe the cause of the Insured’s death (in case of claiming for Accidental Death benefit)","options":[],"required":null,"pdf_field":""},{"help":"Select if autopsy was done","type":"yes-no","label":"Was an autopsy (post mortem) performed?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of medical examiner if autopsy done","type":"text","label":"If yes, provide name, address and contact number of the medical examiner","options":[],"required":null,"pdf_field":""},{"help":"Select if police informed","type":"yes-no","label":"Informed to Police Authority?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Reason if police not informed","type":"text","label":"If No, please provide reason","options":[],"required":null,"pdf_field":""},{"help":"Police FIR number","type":"text","label":"If Yes, FIR No.","options":[],"required":null,"pdf_field":""},{"help":"MLC number if applicable","type":"text","label":"Medico Legal Case (MLC) No.","options":[],"required":null,"pdf_field":""},{"help":"Date of police report","type":"date","label":"Report Date","options":[],"required":null,"pdf_field":""},{"help":"Police station address","type":"text","label":"Address of Police Station","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Payee Details of Primary Insured’s Bank Account","fields":[{"help":"Name of bank account holder","type":"text","label":"Bank Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Bank Branch","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Bank MICR number","type":"text","label":"MICR No.","options":[],"required":null,"pdf_field":""},{"help":"PAN number of account holder","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"To be Filled by Nominee (in the Event of Policy Holder’s Death)","fields":[{"help":"Nominee's full name","type":"text","label":"Name of Nominee","options":[],"required":null,"pdf_field":""},{"help":"Nominee's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Nominee's city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Nominee's state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Nominee's postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Nominee's date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Relationship to deceased insured","type":"text","label":"Relationship with the Deceased","options":[],"required":null,"pdf_field":""},{"help":"Nominee's telephone number","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""},{"help":"Nominee's mobile number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Nominee's email address","type":"email","label":"Email 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":""}],"filled_by":"nominee"},{"title":"Declaration by the Insured","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Insured's signature","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Enclosure Checklist – Hospitalisation Claim","fields":[{"help":"Attach completed and signed claim form","type":"checkbox","label":"Claim Form Duly Filled & Signed","options":["Claim Form Duly Filled & Signed"],"required":null,"pdf_field":""},{"help":"Attach discharge summary","type":"checkbox","label":"Out Patient and/or Hospital Discharge Summary","options":["Out Patient and/or Hospital Discharge Summary"],"required":null,"pdf_field":""},{"help":"Attach doctor's certificate","type":"checkbox","label":"Treating Doctor’s Certificate for Diagnosis of critical illness","options":["Treating Doctor’s Certificate for Diagnosis of critical illness"],"required":null,"pdf_field":""},{"help":"Attach all investigation reports","type":"checkbox","label":"All Investigation Reports","options":["All Investigation Reports"],"required":null,"pdf_field":""},{"help":"Attach final hospital bill","type":"checkbox","label":"Hospital Main Final Bill","options":["Hospital Main Final Bill"],"required":null,"pdf_field":""},{"help":"Attach operation theatre notes if surgery done","type":"checkbox","label":"OT Notes (in surgery case)","options":["OT Notes (in surgery case)"],"required":null,"pdf_field":""},{"help":"Attach CKYC form if claim exceeds Rs.1 lakh","type":"checkbox","label":"CKYC Application Form (if claimed amount is more than Rs.1 Lac)","options":["CKYC Application Form (if claimed amount is more than Rs.1 Lac)"],"required":null,"pdf_field":""},{"help":"Attach photo ID proof","type":"checkbox","label":"Photo Identity Proof","options":["Photo Identity Proof"],"required":null,"pdf_field":""},{"help":"Attach policy and endorsement copy","type":"checkbox","label":"Policy & Endorsement Copy","options":["Policy & Endorsement Copy"],"required":null,"pdf_field":""},{"help":"Attach death certificate if applicable","type":"checkbox","label":"Death Certificate (In Death Claims)","options":["Death Certificate (In Death Claims)"],"required":null,"pdf_field":""},{"help":"Attach doctor's prescription for investigations","type":"checkbox","label":"Doctor’s Prescription for Investigation (CT, HR, VSG, HPE)","options":["Doctor’s Prescription for Investigation (CT, HR, VSG, HPE)"],"required":null,"pdf_field":""},{"help":"Attach PMR certificate if death claim","type":"checkbox","label":"PMR Certificate (in Death Claims)","options":["PMR Certificate (in Death Claims)"],"required":null,"pdf_field":""},{"help":"Attach FIR or MLC copy if applicable","type":"checkbox","label":"FIR/MLC Copy (where applicable)","options":["FIR/MLC Copy (where applicable)"],"required":null,"pdf_field":""},{"help":"Attach indoor case papers if applicable","type":"checkbox","label":"Indoor Case papers. If applicable","options":["Indoor Case papers. If applicable"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Treating Doctor & Hospital","fields":[{"help":"Hospital name","type":"text","label":"Name of the hospital","options":[],"required":null,"pdf_field":""},{"help":"Name of treating doctor","type":"text","label":"Name of the training doctor","options":[],"required":null,"pdf_field":""},{"help":"Hospital or Rohini ID","type":"text","label":"Rohini ID/Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Registration number","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Hospital city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Hospital postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Hospital state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Hospital PAN number","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Number of beds in hospital","type":"number","label":"No. of beds","options":[],"required":null,"pdf_field":""},{"help":"Select if OT available","type":"yes-no","label":"Facilities available in hospital (i) OT","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"treating doctor or hospital"},{"title":"Details of the Patient Admitted","fields":[{"help":"Patient's full name","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Inpatient registration number","type":"text","label":"IP Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Select patient's gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Patient's date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Patient's age","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Date admitted to hospital","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Time admitted (HHMM)","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":""},{"help":"Date discharged from hospital","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Time discharged (HHMM)","type":"text","label":"Time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Select type of admission","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care"],"required":null,"pdf_field":""},{"help":"Select discharge status","type":"choice","label":"Status at the time of Discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Total hospital expenses","type":"amount","label":"Total Hospitalisation Expenses (in ₹)","options":[],"required":null,"pdf_field":""},{"help":"Select room category","type":"choice","label":"Room Category Occupied","options":["Deluxe","Suite","Single Standard","Double Sharing Room","Multi Bedded Room"],"required":null,"pdf_field":""},{"help":"Select if ICU stay occurred","type":"yes-no","label":"Was there any stay in ICU?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"ICU stay start date","type":"date","label":"If ICU Stay, Period of ICU From","options":[],"required":null,"pdf_field":""},{"help":"ICU stay end date","type":"date","label":"To","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital or treating doctor"},{"title":"Details of Ailment Diagnosed (Primary)","fields":[{"help":"Primary diagnosis","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Details of procedures done","type":"text","label":"If any, procedure done, detail description","options":[],"required":null,"pdf_field":""},{"help":"Primary diagnosis detail","type":"text","label":"Primary Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"First procedure done","type":"text","label":"Procedure 1","options":[],"required":null,"pdf_field":""},{"help":"Additional diagnosis if any","type":"text","label":"Additional Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Second procedure done","type":"text","label":"Procedure 2","options":[],"required":null,"pdf_field":""},{"help":"Co-morbid conditions","type":"text","label":"Co-morbidities","options":[],"required":null,"pdf_field":""},{"help":"Third procedure done","type":"text","label":"Procedure 3","options":[],"required":null,"pdf_field":""},{"help":"Details of first procedure","type":"text","label":"Details of Procedure 1","options":[],"required":null,"pdf_field":""},{"help":"Select if present ailment is complication of pre-existing disease","type":"yes-no","label":"Present ailment is a complication of Pre-existing disease","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of pre-existing disease","type":"text","label":"If Yes, specify disease, Its duration and other details","options":[],"required":null,"pdf_field":""},{"help":"Select if hospitalization due to injury","type":"yes-no","label":"Hospitalization due to Injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if injury reported to police","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select cause of injury","type":"choice","label":"Cause of Injury","options":["Self-Inflicted","Road Accident","Any other Accident"],"required":null,"pdf_field":""},{"help":"Select if case is medico legal","type":"yes-no","label":"Is it Medico Legal Case?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if MLC report and FIR attached","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"To be Filled by Treating Doctor","fields":[{"help":"Date patient first consulted doctor","type":"date","label":"Date of first consultation","options":[],"required":null,"pdf_field":""},{"help":"Patient's complaints","type":"text","label":"Presenting Complaints","options":[],"required":null,"pdf_field":""},{"help":"Describe illness or injury nature","type":"text","label":"Nature of illness/injury","options":[],"required":null,"pdf_field":""},{"help":"Medical history reported","type":"text","label":"History reported","options":[],"required":null,"pdf_field":""},{"help":"Extent or severity of illness/injury","type":"text","label":"Extent of Illness/injury","options":[],"required":null,"pdf_field":""},{"help":"Doctor's diagnosis","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Treatment details","type":"text","label":"Treatment given","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"If hospitalized - Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission time","type":"text","label":"Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Hospital discharge time","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Select if similar illness/injury before","type":"yes-no","label":"Has the patient sustained a similar Illness/ injury previously or aggravated a pre-existing condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of previous illness/injury","type":"text","label":"If Yes, please give details","options":[],"required":null,"pdf_field":""},{"help":"Select if injuries solely caused disablement","type":"yes-no","label":"For Personal Accident Cover opted Cover (in case of PA) - Are Injuries sustained in this accident the sole cause of disablement","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Start date of advised rest","type":"date","label":"If injury, please specify the number of days when the injured person is advised rest/unfit and should be confined to bed/house as the direct and sole consequence of the injury sustained From","options":[],"required":null,"pdf_field":""},{"help":"End date of advised rest","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Select if patient can resume duties","type":"yes-no","label":"Will the Injured person be able to attend to his/her normal duties?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date patient can resume duties","type":"date","label":"If Yes, from which date","options":[],"required":null,"pdf_field":""},{"help":"Select if patient was under influence","type":"yes-no","label":"If injury, was he/she under the influence of alcohol/intoxicants or drugs at the time of accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe disablement nature","type":"text","label":"Nature of Disablement","options":[],"required":null,"pdf_field":""},{"help":"Select if permanent total disablement","type":"yes-no","label":"Permanent Total Disablement","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if permanent partial disablement","type":"yes-no","label":"Permanent Partial Disablement","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Percentage of disablement","type":"number","label":"Please specify percentage","options":[],"required":null,"pdf_field":""},{"help":"Percentage of body surface burned","type":"number","label":"Percentage of surface area of Burns","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Declaration by the Hospital","fields":[{"help":"Date of declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of declaration","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Authorized hospital signature","type":"signature","label":"Signature of Hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims under Shri Sarv-Care Health Benefit Package Policy","attachments":["Claim Form Duly Filled & Signed","Out Patient and/or Hospital Discharge Summary","Treating Doctor’s Certificate for Diagnosis of critical illness","All Investigation Reports","Hospital Main Final Bill","OT Notes (in surgery case)","CKYC Application Form (if claimed amount is more than Rs.1 Lac)","Photo Identity Proof","Policy & Endorsement Copy","Death Certificate (In Death Claims)","Doctor’s Prescription for Investigation (CT, HR, VSG, HPE)","PMR Certificate (in Death Claims)","FIR/MLC Copy (where applicable)","Indoor Case papers. If applicable","Cancelled cheque for bank account"],"declarations":["The claimant declares that the information provided is true and correct to the best of their knowledge.","The nominee declares that the particulars are true and authorizes payment as full and final settlement.","The insured declares that the claim information is true and consents to medical information access by TPA/insurance company.","The treating doctor declares that the medical information provided is correct to the best of their knowledge.","The hospital declares that the information furnished is true and correct and acknowledges forfeiture of claim rights if false."],"dropped_labels":8},"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/2368-shri-sarv-care-benefit-health-insurance-claim-form"}