{"id":292,"title":"Clinical Trial 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/Clinical-Trial-Claim-Form.pdf","sha256":"911fae694f9ebd7a09bd99ae4dc18091f2ecd1dae0ba6fcb748a973429b785c7","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Clinical Trials Liability Insurance Policy. It is filled by the insured party who is conducting the clinical trial and reporting an adverse event.","notes":["Complete and return the form without delay even if some particulars are not immediately available.","The form must be signed by an authorized signatory."],"title":"Clinical Trial Insurance – Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Particulars","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Ref No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"1. Insured Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"2. Correspondence Address","options":[],"required":null,"pdf_field":""},{"help":"Name of the contact person for communication","type":"text","label":"3. Contact Person Details","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"4. Contact Number Mobile","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Drug/Protocol Details","fields":[{"help":"Name or identification of the drug or protocol","type":"text","label":"Drug/Protocol Details","options":[],"required":null,"pdf_field":""},{"help":"Version number of the protocol","type":"text","label":"Version","options":[],"required":null,"pdf_field":""},{"help":"Date when permission was granted","type":"date","label":"Date Permission from Drug Controller for conducting trial","options":[],"required":null,"pdf_field":""},{"help":"Total approved subjects for the trial","type":"number","label":"Total Number of subjects (approved) for trial","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Subject Particulars","fields":[{"help":"Code identifying the affected subject","type":"text","label":"Subject Details (affected) Code","options":[],"required":null,"pdf_field":""},{"help":"Initials of the subject","type":"text","label":"Initials","options":[],"required":null,"pdf_field":""},{"help":"Select the gender of the subject","type":"choice","label":"Gender Male (  )  Female ( )","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Number or details of dependents","type":"text","label":"Dependents","options":[],"required":false,"pdf_field":""},{"help":"Monthly salary in rupees","type":"amount","label":"Monthly Salary Rs.","options":[],"required":false,"pdf_field":""},{"help":"Date when subject gave consent","type":"date","label":"Date of consent for conducting trial by subject","options":[],"required":null,"pdf_field":""},{"help":"Name of nominee as per consent form","type":"text","label":"Nominee (as per consent form)","options":[],"required":false,"pdf_field":""},{"help":"Illness or disease of the subject","type":"text","label":"Illness/Disease","options":[],"required":null,"pdf_field":""},{"help":"Date when trial started for the subject","type":"date","label":"Date of Commencement of trial","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Incident Details","fields":[{"help":"Date when adverse event occurred","type":"date","label":"Date of Adverse Event","options":[],"required":null,"pdf_field":""},{"help":"Select where the adverse event occurred","type":"choice","label":"Place of Adverse Event (Home/Hospital)","options":["Home","Hospital"],"required":null,"pdf_field":""},{"help":"Date when you became aware of the event","type":"date","label":"Date when the event came to your knowledge","options":[],"required":null,"pdf_field":""},{"help":"Describe the injuries sustained","type":"text","label":"Nature of injuries","options":[],"required":null,"pdf_field":""},{"help":"Name of hospital conducting the trial","type":"text","label":"Hospital Name where trial was being conducted","options":[],"required":null,"pdf_field":""},{"help":"Name of the doctor supervising the trial","type":"text","label":"Doctor’s Name under whom trial was being conducted","options":[],"required":null,"pdf_field":""},{"help":"Cause of injuries according to enquiry","type":"text","label":"Cause of Injuries as per doctor/hospital enquiry","options":[],"required":null,"pdf_field":""},{"help":"State if notified and date of notification","type":"text","label":"Whether incident has been notified to Ethics Committee, if yes, date of notification","options":[],"required":null,"pdf_field":""},{"help":"Details of any formal claim and amount","type":"text","label":"Whether any formal claim has been lodged by aggrieved party/legal heirs, if yes, please provide claimed amount details also","options":[],"required":null,"pdf_field":""},{"help":"Number of subjects in other trials if any","type":"text","label":"Whether any other trial is being conducted of same protocol, if yes, number of subjects","options":[],"required":false,"pdf_field":""},{"help":"Describe actions taken to prevent recurrence","type":"text","label":"What action insured has taken to avoid further occurrence of adverse event out of said protocol","options":[],"required":false,"pdf_field":""},{"help":"Indicate if legal counsel has been engaged","type":"yes-no","label":"Have you engaged any legal counsel to protect your interest","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of the advocate if engaged","type":"text","label":"If yes, details of the advocate Name","options":[],"required":false,"pdf_field":""},{"help":"Contact number of the advocate","type":"phone","label":"Contact Number","options":[],"required":false,"pdf_field":""},{"help":"Any additional information about the incident","type":"text","label":"In other details/information which you wish to share about the incident","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Name of the authorized signatory","type":"text","label":"Authorized Signatory (Name)","options":[],"required":true,"pdf_field":""},{"help":"Signature of the authorized signatory","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"claims related to adverse events occurring during clinical trials covered under the Clinical Trials Liability Insurance Policy","attachments":[],"declarations":["The issuance of this form is not an admission of liability.","The incident must be notified to the Insurance Company immediately upon knowledge.","If any particulars cannot be immediately given, they may be forwarded later as soon as possible.","If any false or fraudulent statement or concealment is made, the claim shall be forfeited and the policy void."],"dropped_labels":1},"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/292-clinical-trial-insurance-claim-form"}