{"id":2372,"title":"SHRI ALL BENEFIT HEALTH INSURANCE (ABHI) GROUP HEALTH BENEFIT POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/43b43b13-6a39-4162-ae1a-423c0cc1dc60_All_Benefits_-_GROUP_Claim_Form.pdf","sha256":"67e32285c26678f7c89a9d9d07e37c38eefdf44e4f7081c6174b44916851a1d1","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 All Benefit Health Insurance Group Policy. Part B is to be filled by the hospital.","notes":["Attach original bills and documents as per checklist.","Use block letters to fill the form.","Attach cancelled cheque for bank details.","In case of death claims, attach death certificate and PMR certificate.","Attach FIR/MLC copy where applicable.","Hospital section must be completely filled by hospital staff.","Nominee section to be filled only in event of policyholder's death."],"title":"SHRI ALL BENEFIT HEALTH INSURANCE (ABHI) GROUP HEALTH BENEFIT POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A: 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 first joined the policy","type":"date","label":"Date of First Joining the Policy","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured patient","type":"text","label":"1. Name of the Insured Patient","options":[],"required":true,"pdf_field":""},{"help":"Name of person claiming the benefit","type":"text","label":"2. Name of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Relationship of claimant to insured","type":"text","label":"3. Relationship with the Insured","options":[],"required":true,"pdf_field":""},{"help":"DOB of insured patient","type":"date","label":"4. Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"5. Gender Male □ Female □ Others □","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"6. Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6-digit postal code","type":"text","label":"Pin code","options":[],"required":true,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"7. Contact Details Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Email address","type":"email","label":"Email Id","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Section B: Sections Under Which Claiming the Benefit","fields":[{"help":"Tick if claiming this benefit","type":"checkbox","label":"Hospital Daily Cash Benefit","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Cancer Care","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Personal Accident Benefits","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Heart Care","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Criticare Lumpsum Benefit","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Broken Bones","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"EMI Protection","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Accidental Burn Cover","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Out Patient Treatment","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Accidental Hospitalization","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section C: Details of Insurance History","fields":[{"help":"","type":"yes-no","label":"a) Currently covered by any other mediclaim health insurance: Yes □ No □","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"date","label":"b) Date of commencement of first insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"c) If Yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"d) Have you been hospitalized in the last 4 years since inception of the contract Yes □ No □","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide date and duration of hospitalization","type":"text","label":"d(i). If YES (specify Date & duration)","options":[],"required":false,"pdf_field":""},{"help":"Diagnosis details","type":"text","label":"d(ii) If YES (specify the Diagnosis)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"e) Previously covered by any other Mediclaim/Health insurance Yes □ No □","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of previous insurer","type":"text","label":"e(i) If Yes, Company Name","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section D: Details of Illness / Accident / Event During Hospitalization","fields":[{"help":"Name of illness diagnosed","type":"text","label":"1. Diagnosed Illness","options":[],"required":true,"pdf_field":""},{"help":"Symptoms experienced","type":"text","label":"2. Signs & symptoms of Illness","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"3. (i) When was the illness first Diagnosed / detected?","options":[],"required":true,"pdf_field":""},{"help":"Date and time admitted to hospital","type":"date","label":"3. (ii) Date & Time of Admission","options":[],"required":true,"pdf_field":""},{"help":"Date and time discharged from hospital","type":"date","label":"3. (iii) Date & Time of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Doctor who treated the patient","type":"text","label":"4. Name of Treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"Hospital name","type":"text","label":"5. Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"6. Address of Hospital","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal code","type":"text","label":"Pin code","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section E: Details of Accidental Injury Leading to Disability or Death","fields":[{"help":"Name of injured or deceased insured","type":"text","label":"1. Name of the Insured Person dead/injured in the accident","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"2. Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"Select time of accident","type":"choice","label":"Time of Accident AM □ PM □","options":["AM","PM"],"required":true,"pdf_field":""},{"help":"Location of accident","type":"text","label":"3. Place of Accident occurred","options":[],"required":true,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"4. Exact circumstances of accident (attach separate sheet If needed)","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"5. Permanent Disablement? Yes □ No □","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"6. Temporary Disablement? Yes □ No □","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Start date of disablement","type":"date","label":"7. Period of Temporary Total Disablement: From","options":[],"required":false,"pdf_field":""},{"help":"End date of disablement","type":"date","label":"To","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"8. Any Modification of Residential Accommodation or Vehicle done? Yes □ No □","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Amount spent on hospitalization","type":"amount","label":"9. Expenditure towards Hospitalization for the injury or disability management (in Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Amount spent on transportation of mortal remains","type":"amount","label":"10. Expenditure towards transportation on of mortal remains (in Rs.)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"11. Details of the Hospital, where the above Treatment / Management is done; Name of Treating Doctor","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Hospital","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address of Hospital","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"12. Cause of the Insured’s Death (in case of Accidental Death)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"13. Was an autopsy (Post Mortem) performed? Yes □ No □","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If yes, provide name, address and contact number of the medical examiner","options":[],"required":false,"pdf_field":""},{"help":"Provide police report details","type":"text","label":"14. Police Report Details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Informed to Police ? Yes □ No □","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Reason if police not informed","type":"text","label":"If No (please provide reason)","options":[],"required":false,"pdf_field":""},{"help":"FIR number","type":"text","label":"If Yes (provide details) FIR No.","options":[],"required":false,"pdf_field":""},{"help":"MLC number","type":"text","label":"Medico Legal Case (MLC) No.","options":[],"required":false,"pdf_field":""},{"help":"Date of police report","type":"date","label":"Report Date","options":[],"required":false,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Police Station Name","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section F: Details of Any Other Benefit Insurance for Any Illness / Event Claimed","fields":[{"help":"","type":"yes-no","label":"1. Have you incurred any claim under similar Fixed Benefit Plans or any other insurance Yes □ No □","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of other claims","type":"text","label":"If Yes, please provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section G: Payee Details of Primary Insured’s Bank Account","fields":[{"help":"Name as per bank account","type":"text","label":"Bank Account Holder Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"MICR number","type":"text","label":"MICR No.","options":[],"required":false,"pdf_field":""},{"help":"PAN number of account holder","type":"text","label":"PAN No.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section H: To be Filled by Nominee (In the Event of Policy Holder’s Death)","fields":[{"help":"","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Deceased","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Telephone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Nominee's signature","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"nominee"},{"title":"Section I: To be Filled by Employer / Group Policy Holder (Only for Group Policy)","fields":[{"help":"","type":"text","label":"Name of Company / Group policy holder","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address & contact details of the company","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of The Employee","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of joining service","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Designation of Employee","options":[],"required":true,"pdf_field":""},{"help":"Columns: S.NO, Date from which leave is taken, Date when resumed duties, No.of days leave applied, Type of leave, In case of sick leave, Medical Certificate Submitted (YES/ NO), Reason for Leave","type":"table","label":"Please provide the details of leave availed by your employee","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Authorised Signatory","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Seal & Signature of the Signatory Of the Company","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Designation of Signatory","options":[],"required":true,"pdf_field":""}],"filled_by":"employer or group policy holder"},{"title":"Section J: Enclosure Checklist – Hospitalisation Claim","fields":[{"help":"Ensure form is complete and signed","type":"checkbox","label":"Claim Form Duly Filled & Signed","options":[],"required":true,"pdf_field":""},{"help":"Attach discharge summary","type":"attachment","label":"Out Patient and/or Hospital Discharge Summary","options":[],"required":true,"pdf_field":""},{"help":"Attach if applicable","type":"attachment","label":"Treating Doctor’s Certificate for Diagnosis of critical illness","options":[],"required":false,"pdf_field":""},{"help":"Attach all relevant reports","type":"attachment","label":"All Investigation Reports","options":[],"required":true,"pdf_field":""},{"help":"Attach final hospital bill","type":"attachment","label":"Hospital Main Final Bill","options":[],"required":true,"pdf_field":""},{"help":"Attach if surgery done","type":"attachment","label":"OT Notes (in surgery case)","options":[],"required":false,"pdf_field":""},{"help":"Attach if claim > Rs.1 Lac","type":"attachment","label":"CKYC Application Form (if claimed amount is more than Rs.1 Lac)","options":[],"required":false,"pdf_field":""},{"help":"Attach ID proof","type":"attachment","label":"Photo Identity Proof","options":[],"required":true,"pdf_field":""},{"help":"Attach policy documents","type":"attachment","label":"Policy & Endorsement Copy","options":[],"required":true,"pdf_field":""},{"help":"Attach if claim is for death","type":"attachment","label":"Death Certificate (In Death Claims)","options":[],"required":false,"pdf_field":""},{"help":"Attach if investigations done","type":"attachment","label":"Doctor’s Prescription for Investigation (CT, HR, VSG, HPE)","options":[],"required":false,"pdf_field":""},{"help":"Attach if death claim","type":"attachment","label":"PMR Certificate (in Death Claims)","options":[],"required":false,"pdf_field":""},{"help":"Attach if applicable","type":"attachment","label":"FIR/MLC Copy (where applicable)","options":[],"required":false,"pdf_field":""},{"help":"Attach if applicable","type":"attachment","label":"Indoor Case papers. If applicable","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section K: Declaration by the Insured","fields":[{"help":"","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature of insured or claimant","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"}],"deadlines":[],"applies_to":"Group health benefit policy claims under Shri All Benefit Health Insurance","attachments":["Cancelled cheque pertaining to the bank account","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)"],"declarations":["Issuance of this form does not admit liability or waive policy terms; fraudulent claims void the policy and forfeit benefits.","Declaration by nominee: particulars are true; authorize payment as full settlement; indemnify insurer from third party claims.","Declaration by insured: information is true; false statements forfeit claim; consent to share medical info; all bills included; no supplementary claims except pre/post hospitalization.","Declaration by hospital: information is true; false statements forfeit claim rights."],"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/2372-shri-all-benefit-health-insurance-abhi-group-health-benefit-policy-claim-form"}