{"id":2384,"title":"Janata Personal Accident Insurance Claim Form","purpose":"claim","insurer":{"slug":"united-india-insurance","name":"United India Insurance Company Limited"},"source_pdf":"https://uiic.co.in/web/sites/default/files/Policy-Document/Rural%20%26%20Social%20-%20Revised%20Janata%20Personal%20Accident%20Insurance.pdf","sha256":"8bb071bf82f21e843dd10502082261842f27afbf5d8979f63ffde276b1e7936e","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person, nominee, legal heir, or appointee to claim benefits under the Janata Personal Accident Insurance policy after an accident causing death or permanent disability.","notes":["Issuance of this form or registration of claim does not constitute admission of liability.","All questions must be answered completely and accurately; write 'Not Applicable' or 'N/A' where not applicable.","The Treating Doctor's Certificate / Medical Report (Annexure 1) is mandatory and must be submitted with this form.","Only one of the accidental death or permanent total disablement benefits can be claimed for the same injury as per policy condition.","NEFT payment is mandatory; attach cancelled cheque or bank passbook copy.","Use the prescribed formats for dates (DD/MM/YYYY)."],"title":"Janata Personal Accident Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claim Intimation Details","fields":[{"help":"","type":"text","label":"Claim Intimation No. (if already intimated)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Master Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Certificate No. (if issued)","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Policyholder / Group Administrator Details","fields":[{"help":"","type":"text","label":"Name of Policyholder / Group Organiser","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Include country and area code if applicable","type":"phone","label":"Contact Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Contact Person (if any)","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Details of Insured Person (Injured / Deceased)","fields":[{"help":"","type":"text","label":"Full Name of Insured Person","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Employee ID / Membership No. (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Specify type and number","type":"text","label":"Photo ID Proof Type & Number (Aadhaar / PAN / Voter ID / Passport etc.)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nominee Name (as per policy schedule)","options":[],"required":true,"pdf_field":""},{"help":"Relationship to insured person","type":"text","label":"Relationship","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Nature of Claim","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Accidental Death - 100% of Capital Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Permanent Total Disablement (PTD) – 100% of Capital Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Tick if applicable; only one claim allowed per injury","type":"checkbox","label":"Permanent Total Disablement (PTD) – 50% of Capital Sum Insured","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Accident Details","fields":[{"help":"DD/MM/YYYY format","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"Specify time and AM/PM","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"Location where accident occurred","type":"text","label":"Place of Accident","options":[],"required":true,"pdf_field":""},{"help":"Describe the accident circumstances","type":"text","label":"Detailed description of how the accident occurred","options":[],"required":true,"pdf_field":""},{"help":"Describe injuries","type":"text","label":"Nature & extent of injuries sustained","options":[],"required":true,"pdf_field":""},{"help":"Provide specialist certification details","type":"text","label":"If Permanent Disability, exact nature of disability (must be certified by specialist)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the Insured Person under the influence of alcohol / intoxicants at the time of accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the accident related to any excluded activity in the policy (adventure sports, racing, aviation other than fare-paying passenger, war, suicide, criminal act etc.)?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Police & Medico-Legal Information","fields":[{"help":"","type":"yes-no","label":"Was the accident reported to Police?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide FIR or NCR number if applicable","type":"text","label":"If Yes – FIR / NCR No.","options":[],"required":false,"pdf_field":""},{"help":"Name and address of police station","type":"text","label":"Police Station & address","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is / Was the case treated as a Medico-Legal Case (MLC)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide MLC number if applicable","type":"text","label":"If Yes – MLC No.","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Hospitalisation & Treatment Details (if applicable)","fields":[{"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":"DD/MM/YYYY format","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name(s) of Treating Doctor(s)","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Claimant / Person Entitled to Receive Claim Payment","fields":[{"help":"Tick the applicable category","type":"choice","label":"Person entitled to receive claim payment","options":["Insured person (self)","Nominee (as per policy schedule)","Legal Heir (if no subsisting nominee)","Appointee (where nominee is a minor)","Assignee (in case the benefit has been absolutely assigned)"],"required":true,"pdf_field":""},{"help":"Name of claimant","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Relationship to insured person","type":"text","label":"Relationship with Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Phone number of claimant","type":"phone","label":"Contact No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Bank Details for Claim Payment (NEFT Mandatory)","fields":[{"help":"","type":"text","label":"Account Holder Name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"PAN of Payee","options":[],"required":true,"pdf_field":""},{"help":"Attach a cancelled cheque or bank passbook copy for NEFT verification","type":"attachment","label":"Attach cancelled cheque or bank passbook copy","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"List of Documents Attached","fields":[{"help":"Attach for all claim types","type":"checkbox","label":"Policy Schedule / Certificate of Insurance","options":[],"required":true,"pdf_field":""},{"help":"Attach the completed claim form","type":"checkbox","label":"Duly completed & signed Claim Form","options":[],"required":true,"pdf_field":""},{"help":"For accidental death claims","type":"checkbox","label":"Death Certificate","options":[],"required":false,"pdf_field":""},{"help":"For accidental death claims","type":"checkbox","label":"Post-Mortem Report (with viscera/chemical analysis if done)","options":[],"required":false,"pdf_field":""},{"help":"For accidental death and disability claims where applicable","type":"checkbox","label":"FIR / Panchnama Report","options":[],"required":false,"pdf_field":""},{"help":"For accidental death claims","type":"checkbox","label":"Medico-Legal Certificate (MLC)","options":[],"required":false,"pdf_field":""},{"help":"Attach all relevant medical documents","type":"checkbox","label":"Medical records / treatment papers (if any)","options":[],"required":false,"pdf_field":""},{"help":"For accidental death claims","type":"checkbox","label":"Photo ID & Address proof of deceased & nominee/legal heirs","options":[],"required":false,"pdf_field":""},{"help":"For accidental death claims if no nominee","type":"checkbox","label":"Legal Heirship Certificate / Succession Certificate (if no nominee) + Indemnity Bond","options":[],"required":false,"pdf_field":""},{"help":"Mandatory for claim payment","type":"checkbox","label":"NEFT Mandate Form + Cancelled Cheque","options":[],"required":true,"pdf_field":""},{"help":"For permanent total disablement claims","type":"checkbox","label":"Disability Certificate from treating specialist clearly stating the exact disability","options":[],"required":false,"pdf_field":""},{"help":"For permanent total disablement claims","type":"checkbox","label":"Photographs of the Insured Person clearly showing the disability (face visible)","options":[],"required":false,"pdf_field":""},{"help":"Attach if requested","type":"checkbox","label":"Any other document requested by the Company","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Declaration & Consent","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature / Thumb Impression of Claimant /Nominee / Legal Heir","options":[],"required":true,"pdf_field":""},{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant / nominee / legal heir"},{"title":"Annexure 1: Treating Doctor’s Certificate / Medical Report","fields":[{"help":"","type":"text","label":"Name of the Patient (Injured/Deceased)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Specify date and time","type":"text","label":"Date & Time of Accident","options":[],"required":true,"pdf_field":""},{"help":"Specify date and time","type":"text","label":"Date & Time of First Consultation","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Admission (if hospitalized)","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Discharge / Death","options":[],"required":false,"pdf_field":""},{"help":"Describe accident and injuries","type":"text","label":"Nature of the Accident/Incident and details of injuries sustained","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Cause of Accident/Incident","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"In your opinion, are the injuries / disability / death solely due to Accident/Incident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, specify disease","type":"yes-no","label":"In your opinion, are the injuries / disability / death traceable to any disease? (If Yes, specify)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, specify previous injury","type":"yes-no","label":"In your opinion, are the injuries / disability / death traceable to any previous injury? (If Yes, specify)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient under the influence of alcohol, drugs, or intoxicants at the time of accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Mark all applicable","type":"checkbox","label":"Is the patient currently suffering from a Total and Irrecoverable Loss of any of the following? (Please mark all that apply)","options":["Both hands","Both feet","One hand and one foot","One hand/foot and one eye","Sight of both eyes","Speech and hearing of both ears"],"required":false,"pdf_field":""},{"help":"Mark all applicable","type":"checkbox","label":"Is the patient suffering from a Total and Irrecoverable Loss of any of the following? (Please mark all that apply)","options":["One hand/foot","Sight of an eye"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Any other Permanent Total Disability (not listed above) that permanently prevents the patient from doing any job or occupation for earnings?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is the disablement Permanent & Total in nature and likely to continue for the remainder of the patient’s life?","options":["Yes","No","Not applicable"],"required":true,"pdf_field":""},{"help":"Specify expected recovery period","type":"text","label":"If No, expected period of recovery","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If the patient has expired, was death caused solely and directly due to the accident and independent of any other cause?","options":["Yes","No","Not applicable"],"required":true,"pdf_field":""},{"help":"Specify other causes if death not solely due to accident","type":"text","label":"If No, please specify contributing factors","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Any other remarks / observations relevant to the claim","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Registration No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Hospital / Clinic Name & Address","options":[],"required":false,"pdf_field":""},{"help":"Date of certificate (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of certificate","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature and hospital stamp","type":"signature","label":"Signature of Treating Doctor & Hospital Seal / Stamp","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"Janata Personal Accident – Individual and Group policies","attachments":["Duly completed and signed Treating Doctor's Certificate / Medical Report (Annexure 1)","Policy Schedule / Certificate of Insurance","Death Certificate (for accidental death claims)","Post-Mortem Report (with viscera/chemical analysis if done)","FIR / Panchnama Report","Medico-Legal Certificate (MLC)","Medical records / treatment papers","Photo ID & Address proof of deceased & nominee/legal heirs","Legal Heirship Certificate / Succession Certificate (if no nominee) + Indemnity Bond","NEFT Mandate Form + Cancelled Cheque","Disability Certificate from treating specialist (for permanent total disablement claims)","Photographs of the Insured Person clearly showing the disability (face visible)"],"declarations":["The information furnished is true and correct to the best of the claimant's knowledge and belief.","Authorise United India Insurance Co. Ltd. to seek any medical information / records from any hospital / doctor who attended the Insured Person.","Authorise the Company or its representatives to examine the Insured Person whenever required."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"mayfair.claims@mayfairwecare.com","label":"Overseas Mediclaim Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Worldwide - Excluding USA & Canada -","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"mayfairassist@mayfairwecare.com","label":"Overseas Mediclaim Medical Emergency Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"://www.mayfairwecare.com/contact/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Wor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18004190133","label":"Overseas Mediclaim Policy Toll-Free Number (India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"l - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact/\nWebsite\nhttps://w","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18888811701","label":"Overseas Mediclaim Policy Toll-Free Number (United States)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"ss\nTower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Loc","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08083045211","label":"Overseas Mediclaim Policy Toll-Free Number (United Kingdom)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"nowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please v","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18885192693","label":"Overseas Mediclaim Policy Toll-Free Number (Canada)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"annerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.may","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8003211710","label":"Overseas Mediclaim Policy Toll-Free Number (Singapore)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"lore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001236889","label":"General Contact Number","level":null,"hours":null,"applies_to":"all","source_url":"https://uiic.co.in/web/","quote":"Links\nCustomer Portal\nKYC Process\nFacebook\nInstagram\nYoutube\nTwitter\nOffice Locator\nIntermediary Portal\nDigi Locker\ntel:18001236889","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/united-india-insurance/2384-janata-personal-accident-insurance-claim-form"}