{"id":30,"title":"ACKO 360 PROTECT CLAIM FORM","purpose":"claim","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/Claims_Form_Acko_360_Protect_2c98790a88.pdf","sha256":"db4308a274f1a448cedd80e294cc5f28d9bd1528feca139ccaa722cc4f08c51e","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the Acko 360 Protect insurance policy.","notes":["Complete the form in CAPITAL LETTERS.","Do not leave any column unanswered; mention 'N/A' if not applicable.","Attach original witness statements if already obtained.","Attach all required documents as per the claim type and benefit category.","Submission of documents or bank details does not imply admission of liability by the company.","For EFT payment, attach original blank cancelled cheque and PAN card copy.","The RTGS/NEFT facility will be activated within 15 days of receipt of mandate form.","The customer is responsible for accuracy of bank details provided.","The customer may terminate EFT facility with 15 days prior written notice to Acko.","Use recent ID/address proof and photograph for KYC requirements.","Additional documents may be requested as needed."],"title":"ACKO 360 PROTECT CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"DETAILS OF POLICYHOLDER","fields":[{"help":"Enter the group name if applicable","type":"text","label":"Group Name","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the policyholder's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the type of business","type":"text","label":"Type of Business","options":[],"required":null,"pdf_field":""},{"help":"Enter full address including city, state, and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Telephone Number: Mobile","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF THE INSURED PERSON IN RESPECT OF WHOM CLAIM IS MADE","fields":[{"help":"Enter the primary insured person's name","type":"text","label":"Name of Primary Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's full name","type":"text","label":"Name of claimant","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's full address including city, state, and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Telephone Number: Mobile","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter certificate number","type":"text","label":"Certificate of Insurance No","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to policyholder","type":"text","label":"Relationship with Policyholder","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Injury/Illness","options":[],"required":null,"pdf_field":""},{"help":"Enter time in HH:MM hrs format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Enter location of accident or injury","type":"text","label":"Place of Accident/Injury","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details and nature","type":"text","label":"Details of Accident and Nature of Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe illness details","type":"text","label":"Details of Illness (Date, Location and Nature of Illness)","options":[],"required":null,"pdf_field":""},{"help":"Indicate if accident was reported to police","type":"yes-no","label":"Whether accident reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide police station details if reported","type":"text","label":"If Yes, Name and Address of Police Station","options":[],"required":false,"pdf_field":""},{"help":"Explain why accident was not reported","type":"text","label":"If No, Give reasons","options":[],"required":false,"pdf_field":""},{"help":"Provide FIR/MLC/missing complaint number if applicable","type":"text","label":"First Information Report (FIR)/ Medico Legal Certificate (MLC)/ Missing complaint No.","options":[],"required":false,"pdf_field":""},{"help":"Date of FIR/MLC/missing complaint","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Provide police station contact details","type":"text","label":"Contact Details of Police Station","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF HOSPITALIZATION (IN CASE OF ACCIDENT/ILLNESS/CRITICAL ILLNESS)","fields":[{"help":"Indicate if hospitalization occurred","type":"yes-no","label":"Whether Insured Person hospitalized after the Accident/Illness/Critical Illness","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide hospital name and address if hospitalized","type":"text","label":"Name and Address of the Hospital","options":[],"required":false,"pdf_field":""},{"help":"Enter admission date in DD/MM/YYYY format","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Enter discharge date in DD/MM/YYYY format","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF WITNESSES (in case of Accident)","fields":[{"help":"Indicate if there were witnesses","type":"yes-no","label":"Was there any witness to the Accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter witness name if applicable","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Enter witness address including city, state, pin code","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Enter city of witness","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Enter state of witness","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter pin code of witness","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Enter witness mobile number","type":"phone","label":"Telephone Number: Mobile","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF BENEFITS CLAIMED","fields":[{"help":"Provide details if applicable","type":"text","label":"Name and Address of Mortgages(s) or other persons having financial interest in the property","options":[],"required":false,"pdf_field":""},{"help":"Enter date of loss","type":"date","label":"DETAILS OF LOSS/ACCIDENT - Date of loss","options":[],"required":null,"pdf_field":""},{"help":"Enter time of loss","type":"text","label":"Time of loss","options":[],"required":null,"pdf_field":""},{"help":"Provide address for inspection","type":"text","label":"Address where the loss can be inspected","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss or damage","type":"text","label":"Describe Cause of Loss/Damage","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated loss amounts for each category","type":"table","label":"Estimated Loss (₹) - Building, Additional Structures, Others, General Home Contents, Loss of Rent / Rent for Alternative Accommodation","options":[],"required":null,"pdf_field":""},{"help":"Indicate if witnesses were present","type":"choice","label":"Witness Details - Were there any witnesses to the loss/accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter names of witnesses if any","type":"text","label":"Name of the persons","options":[],"required":false,"pdf_field":""},{"help":"Enter address of witnesses","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Provide contact details of witnesses","type":"text","label":"Contact Details - Phone, Mobile, Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"Information to authority","fields":[{"help":"Indicate if loss was reported to any authority","type":"choice","label":"Has the loss been reported to an Authority?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain reason if not reported","type":"text","label":"If 'No', reason for not reporting","options":[],"required":false,"pdf_field":""},{"help":"Select applicable authorities","type":"checkbox","label":"If 'Yes', provide details - Fire, Police, Municipality, Others (checkboxes)","options":["Fire","Police","Municipality","Others"],"required":false,"pdf_field":""},{"help":"Provide name of authority","type":"text","label":"Name of authority","options":[],"required":false,"pdf_field":""},{"help":"Provide report or reference number","type":"text","label":"Information Report No/ Authority Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of report","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of contact person at authority","type":"text","label":"Contact Person Name","options":[],"required":false,"pdf_field":""},{"help":"Address of authority","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Contact details of authority","type":"text","label":"Contact Details - Phone, Mobile, Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF OTHER INSURANCE","fields":[{"help":"Indicate if other insurance covers loss","type":"choice","label":"Is the loss/damage covered under any other Insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide insurer name, policy number, sum insured, policy period","type":"text","label":"If 'Yes', specify details and attach a copy of the policy","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Name of the Insurer","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":"Start date of other policy","type":"date","label":"Policy Period: From","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF OTHER INTEREST","fields":[{"help":"Indicate ownership status","type":"choice","label":"Is the Insured the Sole Owner of the property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe nature of interest if not sole owner","type":"text","label":"Nature of interest","options":[],"required":false,"pdf_field":""},{"help":"Address of other interested party","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Contact details of other interested party","type":"text","label":"Contact Details - Phone, Mobile, Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF PREVIOUS LOSSES (Losses during the 3 preceding years)","fields":[{"help":"List previous losses with details","type":"table","label":"Date of Loss, Claim Description and Cause of Loss, Value of Loss (Rs.), Insurer","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF OTHER INFORMATION","fields":[{"help":"Provide any other relevant information","type":"text","label":"Other Information","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DETAILS OF BANK ACCOUNT FOR CLAIM PAYMENT","fields":[{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/Claimant"},{"title":"DIRECT FUND TRANSFER / EFT MANDATE FORM","fields":[{"help":"Select Yes or No","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter payee name if opting for EFT","type":"text","label":"Payee Name (as per bank records)","options":[],"required":false,"pdf_field":""},{"help":"Enter payee bank account number","type":"text","label":"Payee Account No.","options":[],"required":false,"pdf_field":""},{"help":"Enter account type","type":"text","label":"Type of Account","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank address","type":"text","label":"Address of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR Code No. of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Permanent Account Number (PAN) of Payee","options":[],"required":false,"pdf_field":""},{"help":"Attach original cancelled cheque","type":"attachment","label":"Attach an ORIGINAL BLANK CANCELLED CHEQUE signed by the Payee","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"attachment","label":"Attach a PAN CARD copy of Payee","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant"}],"deadlines":[],"applies_to":"Claims under Acko 360 Protect insurance policies","attachments":["Our claim form duly completed and signed","Copies of valid KYC documents of the Nominee/claimant","Legal heir certificate (if applicable)","Copy of FIR/MLC (if applicable)","Hospital main bill, break-up bill, bill payment receipt, discharge summary, operation theatre notes, Doctor’s request for investigation (if applicable)","Death Certificate attested by issuing/ appropriate authority (if applicable)","Leave certificate from the employer (Hospitalization claims)","Name and address of the attending Medical Practitioner","Medical reports, case histories, investigation reports, treatment papers as applicable","Discharge summary/certificate","Certification of disability along with percentage of disability/ Photograph of the injured with reflecting disablement (if applicable)","Additional documents depending on the nature of the claim as requested","Copy of vehicle RC and driver’s license (for optional benefits)","Photographs (if required by insurer)","Any other document (if required)","Original blank cancelled cheque signed by the Payee","PAN CARD copy of Payee"],"declarations":["The information provided in this claim form is true, correct and complete.","All persons having an interest in the property are disclosed and no duplicate claims have been made.","No material information relevant to the claim has been withheld.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this claim form or documents does not imply admission of liability by the insurer."],"dropped_labels":10},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102","label":"Claims postal address","level":null,"hours":null,"applies_to":"life","source_url":"https://acko-cms.ackoassets.com/2_Acko_Life_Group_Term_Protect_Micro_Insurance_Master_Policy_Document_ca9093f4de.pdf","quote":"at claims.life@acko.com or by sending the documents to the address mentioned below or any other office of the Company:\nClaims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102\n\nAny person claiming the Death Benefit under this Policy can download the claim request documents from Our website www.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-210-1992","label":"Claims phone number","level":null,"hours":"9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/claims/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nACKO Life Insurance Claims Process\nGroup Claims Process\nClaims Pro","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/acko-life-insurance/30-acko-360-protect-claim-form"}