{"id":282,"title":"SECTION 11 B - EMPLOYEES COMPENSATION INSURANCE CLAIM FORM","purpose":"claim","insurer":{"slug":"iffco-tokio-general-insurance","name":"IFFCO TOKIO General Insurance Company Limited"},"source_pdf":"https://www.iffcotokio.co.in/content/dam/iffcotokio/iffco-pdf/sites/default/files/pdf/Employees-Compensation-Claim-Form-All-in-One-Home-Protector.pdf","sha256":"e368d37c25f1cb8d00903ac886f154cfcda3cbb974e28a0a623c52d3688b3bc1","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for the employer to claim employees compensation insurance under the All In One Home Protector Policy. The employer fills it to report an accident involving an employee and provide details of the injury and earnings.","notes":["Fill all blanks completely; attach separate sheet if space is insufficient.","Do not delay sending the form if some information is not readily available; send supplementary advice later.","Answer all questions whether or not a claim has been made or anticipated.","If the injured person has been in service less than 12 months, provide date of entry and adjust period of service for absences over 14 days.","In the earnings table, provide dates of absences and resumption of work.","Use original documents for attachments if required."],"title":"SECTION 11 B - EMPLOYEES COMPENSATION INSURANCE CLAIM FORM","submit":{"to":"ADDRESS OF POLICY ISSUING OFFICE","how":"","address":""},"purpose":"claim","sections":[{"title":"PART – I THE EMPLOYER","fields":[{"help":"","type":"text","label":"Name of Policy holder","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"State name and postal pin code","type":"text","label":"State & Pin Code","options":[],"required":true,"pdf_field":""}],"filled_by":"employer"},{"title":"PART – II PARTICULARS OF INJURED PERSON","fields":[{"help":"Name of the injured employee","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Religion or Caste","options":[],"required":false,"pdf_field":""},{"help":"Current address of injured person","type":"text","label":"Local Address","options":[],"required":true,"pdf_field":""},{"help":"Permanent residential address","type":"text","label":"Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Job or role of the injured person","type":"text","label":"Occupation in which injured person is employed","options":[],"required":true,"pdf_field":""},{"help":"Describe the task being performed during accident","type":"text","label":"On what work was injured person engaged at the time of accident?","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person actually working when the accident occurred?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If not directly employed, provide contractor details","type":"text","label":"Is injured person in your direct employment? (if not give name & address of Contractor and Nature of Contract)","options":[],"required":true,"pdf_field":""},{"help":"Hospital where injured person was admitted","type":"text","label":"Name of the Hospital taken to","options":[],"required":false,"pdf_field":""},{"help":"Current hospitalization status or discharge date","type":"text","label":"State whether still in Hospital, or when discharged","options":[],"required":false,"pdf_field":""}],"filled_by":"employer"},{"title":"PART – II (continued) Injury and Work Details","fields":[{"help":"Describe injury details and affected body parts","type":"text","label":"State nature of injury, body parts injured and whether left or right","options":[],"required":true,"pdf_field":""},{"help":"Date work stopped due to injury","type":"text","label":"Did person actually cease work and if so, on what date ?","options":[],"required":false,"pdf_field":""},{"help":"Date of return to work if applicable","type":"text","label":"Has injured person resumed duty since and if so, on what date?","options":[],"required":false,"pdf_field":""},{"help":"Estimated duration of disability","type":"text","label":"What is the probable period of disablement? (approximate)","options":[],"required":false,"pdf_field":""},{"help":"Details of any pre-existing infirmity","type":"text","label":"Was the injured person free from physical infirmity at the time of accident? If not, give particulars","options":[],"required":false,"pdf_field":""}],"filled_by":"employer"},{"title":"PART – III PARTICULARS OF ACCIDENT","fields":[{"help":"Date when accident occurred","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"Location of accident if not on home premises","type":"text","label":"Did the accident occur actually within your home premises? If not, where did it occur?","options":[],"required":true,"pdf_field":""},{"help":"Date and source of accident notification; attach written notice if any","type":"text","label":"On what date did you receive notice of accident and from whom? If in writing please attach to this form","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you satisfied that injured person met with a bonafide accident of employment","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Detailed description of accident circumstances","type":"text","label":"How exactly did the accident occur?","options":[],"required":true,"pdf_field":""},{"help":"Safety measures on machinery","type":"text","label":"If accident due to machinery, state: (a) Whether it was fenced or guarded","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"(b) Was it being cleaned whilst in motion","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was injured person under the influence of alcohol or drugs at the time of the accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of any misconduct if applicable","type":"text","label":"Was he guilty of misconduct or disobedience to orders or rules? If so, please give full particulars","options":[],"required":false,"pdf_field":""},{"help":"Name of person responsible if known","type":"text","label":"State through whose neglect, if any, it occurred","options":[],"required":false,"pdf_field":""},{"help":"Names of two accident witnesses","type":"text","label":"State the names of any two persons who witnessed the accident","options":[],"required":true,"pdf_field":""},{"help":"Names of supervisors or overseers","type":"text","label":"Give names of overlooker or persons in Superintendence.","options":[],"required":false,"pdf_field":""}],"filled_by":"employer"},{"title":"Declaration by Employer","fields":[{"help":"Name of person signing declaration","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Signature of employer or authorized person","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"employer"},{"title":"STATEMENT OF INJURED PERSON’S EARNINGS","fields":[{"help":"Date employee joined service","type":"date","label":"Date on which injured person first entered service","options":[],"required":true,"pdf_field":""},{"help":"Date of return after long absence if applicable","type":"date","label":"Date on which the injured person resumed duty after a continuous absence of more than 14 days","options":[],"required":false,"pdf_field":""},{"help":"Fill monthly wages, allowances, and absences for 12 months prior to accident; include dates of absences","type":"table","label":"Month & Year, Wages Earned (Including Overtime), Value of bonus, food subsidy, if any, free quarters and any other allowance, etc., Absences","options":[],"required":true,"pdf_field":""},{"help":"Total wages including allowances for the period","type":"amount","label":"Total earning in the period from___________ to ___________","options":[],"required":true,"pdf_field":""},{"help":"Sum of all earnings and allowances","type":"amount","label":"Total earnings, including all allowances","options":[],"required":true,"pdf_field":""},{"help":"Average monthly wage calculated","type":"amount","label":"Monthly average wages","options":[],"required":true,"pdf_field":""},{"help":"Provide average wages if service less than one month","type":"amount","label":"If the employee’s period of service was less than one month, give the average monthly wages of an employee employed on similar work Rs.","options":[],"required":false,"pdf_field":""},{"help":"Describe allowances or bonuses included","type":"text","label":"Please state the exact nature of the allowance and / or bonus.","options":[],"required":false,"pdf_field":""},{"help":"Details of absences with dates","type":"text","label":"In the column “absence”, please give the date of going on leave or beginning of period of absence and also date of subsequent resumption of work.","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature confirming correctness of earnings statement","type":"signature","label":"Signature of Employer","options":[],"required":true,"pdf_field":""},{"help":"Additional accident details if any","type":"text","label":"add below any additional information available regarding the accident","options":[],"required":false,"pdf_field":""},{"help":"Additional signature if needed","type":"signature","label":"Signature of Employer","options":[],"required":false,"pdf_field":""}],"filled_by":"employer"}],"deadlines":["Please return this form, duly filled & signed, within 7 days from the date of occurrence"],"applies_to":"Employees Compensation Insurance claims under All In One Home Protector Policy","attachments":["Written notice of accident if available"],"declarations":["All statements made on this form are true to the best of my/our knowledge and belief.","If any false or fraudulent statement, suppression or concealment is made, the claim shall be forfeited and the policy null and void.","I/We confirm that the earnings details are true and correct to the best of my/our knowledge."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"policy issuing Branch","label":"Walk in claim intimation","level":null,"hours":"Mon- Fri 09:30 AM to 06:00 PM (Except for National Holidays)","applies_to":"all","source_url":"https://www.iffcotokio.co.in/claims/register-a-claim","quote":"65 days.\nToll No. 1800-103-5499\nWalk in\nShall you wish to intimate your claim in person, please feel free to visit your policy issuing Branch Mon- Fri 09:30 AM to 06:00 PM (Except for National Holidays). Please refer to our\nBranch Locator\nfor information on our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"support@iffcotokio.co.in","label":"Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.iffcotokio.co.in/contact-us/customer-services/grievance-redressal","quote":"se\nTelugu\nOriya\nPolicy Copy\nService Request\nLocators\nClaims\nRegister Claim\nClaim Status\nToll free: 1800-103-5499\nEmail: support@iffcotokio.co.in\nSay Hi to IRA: 7993407777\nEnglish\nHindi\nMarathi\nGujarati\nPunjabi\nMalayalam\nTamil\nBengali\nKannada\nAssamese\nTelugu\nOriya","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-5499","label":"Toll free","level":null,"hours":"24 X 7","applies_to":"all","source_url":"https://www.iffcotokio.co.in/contact-us/customer-services/grievance-redressal","quote":"engali\nKannada\nAssamese\nTelugu\nOriya\nPolicy Copy\nService Request\nLocators\nClaims\nRegister Claim\nClaim Status\nToll free: 1800-103-5499\nEmail: support@iffcotokio.co.in\nSay Hi to IRA: 7993407777\nEnglish\nHindi\nMarathi\nGujarati\nPunjabi\nMalayalam\nTamil\nBengal","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"sms","value":"56161","label":"SMS “CLAIM” to 56161","level":null,"hours":null,"applies_to":"all","source_url":"https://www.iffcotokio.co.in/claims/register-a-claim","quote":"avor to take customer service at newer heights, we now bring claim Intimation at your fingertips. Please SMS “CLAIM” to 56161 and one of our Claims representatives will get in touch with you in 4 Working Hours.\n* Note:\nPlease have all the detail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"whatsapp","value":"7993407777","label":"Say Hi to IRA","level":null,"hours":null,"applies_to":"all","source_url":"https://www.iffcotokio.co.in/contact-us/customer-services/grievance-redressal","quote":"est\nLocators\nClaims\nRegister Claim\nClaim Status\nToll free: 1800-103-5499\nEmail: support@iffcotokio.co.in\nSay Hi to IRA: 7993407777\nEnglish\nHindi\nMarathi\nGujarati\nPunjabi\nMalayalam\nTamil\nBengali\nKannada\nAssamese\nTelugu\nOriya\nCustomer Login\nAgent Login","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/iffco-tokio-general-insurance/282-section-11-b-employees-compensation-insurance-claim-form"}