{"id":386,"title":"CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE","purpose":"claim","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/gpa-claim-form8c0007ff45fd68ff8a0df0055f65b1d8.pdf","sha256":"797278524ffcbb2bc55bd4c0ed21dd6c94348199de04d5f620c40d1418e4394f","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used to claim personal accident insurance benefits and is filled by the insured person, claimant, hospital authorities, employer, or nominee as applicable.","notes":["Please answer all questions fully.","Attach original blank cancelled cheque signed by the payee and PAN card copy for EFT payment.","Submit self-attested copy of valid government-issued identity proof of claimant/insured with consent letter.","The issuance of this form is not to be taken as an admission of liability.","Use block letters where applicable.","Consent letter authorizes ICICI Lombard to collect medical records from hospital or medical practitioner.","Submission of documents or bank details does not imply admission of liability by the company."],"title":"CLAIM FORM FOR PERSONAL ACCIDENT INSURANCE","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016.","how":"post","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016."},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"H.No. :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Building/Street Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Area :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Land mark:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal PIN code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid mobile or contact number","type":"phone","label":"Contact / Mobile No :","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Details of Injured/Deceased Person","fields":[{"help":"","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"H.No. :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Building/Street Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Area :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Land mark:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal PIN code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid mobile or contact number","type":"phone","label":"Contact / Mobile No :","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age :","options":[],"required":null,"pdf_field":""},{"help":"Provide designation, employee ID and date of joining if applicable","type":"text","label":"Designation, Employee Id & Date of Joining","options":[],"required":null,"pdf_field":""},{"help":"Enter date and time of the accident or death","type":"date","label":"Date & time of injury/death :","options":[],"required":null,"pdf_field":""},{"help":"Specify location where injury or death occurred","type":"text","label":"Place of injury/ death :","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident in detail","type":"text","label":"Detailed Description of the accident :","options":[],"required":null,"pdf_field":""},{"help":"Indicate if the accident was reported to police","type":"yes-no","label":"Whether reported to Police :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide police station details if reported","type":"text","label":"If yes then name and address of Police Station :","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Hospitalization Details","fields":[{"help":"Indicate if hospital admission was immediate","type":"yes-no","label":"Was the injured /deceased person shifted to hospital immediately after the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide hospital name and address if admitted","type":"text","label":"If yes , Name & address of the hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Other Personal Accident Policy Details","fields":[{"help":"Indicate if you hold any other personal accident policy","type":"yes-no","label":"Do you have any other Personal Accident Policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide address of other insurer's issuing office","type":"text","label":"If yes, please give Address of the issuing office  :","options":[],"required":null,"pdf_field":""},{"help":"Provide policy number of other personal accident policy","type":"text","label":"Policy No. :","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Declaration by Insured/Employer","fields":[{"help":"Indicate if injured person was absent from work","type":"yes-no","label":"Was the injured person in respect of whom claim being made absent from work?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter start date of absence","type":"date","label":"If so, please furnish the details of such absence : Leave From :","options":[],"required":null,"pdf_field":""},{"help":"Enter end date of absence","type":"date","label":"To :","options":[],"required":null,"pdf_field":""},{"help":"Date of declaration","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of the injured person","type":"signature","label":"Signature of the Injured Person","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or employer"},{"title":"Hospital Authorities Section","fields":[{"help":"Provide hospital name and address","type":"text","label":"Name and address of the hospital :","options":[],"required":null,"pdf_field":""},{"help":"Date of hospital admission","type":"date","label":"Date of admission :","options":[],"required":null,"pdf_field":""},{"help":"Date of hospital discharge","type":"date","label":"Date of discharge :","options":[],"required":null,"pdf_field":""},{"help":"Describe the injury","type":"text","label":"Nature of injury :","options":[],"required":null,"pdf_field":""},{"help":"Details of treatment provided","type":"text","label":"Particulars of treatment :","options":[],"required":null,"pdf_field":""},{"help":"Start date of advised rest","type":"date","label":"If Claim is related to Temporary Total Disability (As in patient / out patient /emergency case): Advised rest/ unfit to work for specified number of days. From :","options":[],"required":null,"pdf_field":""},{"help":"End date of advised rest","type":"date","label":"To :","options":[],"required":null,"pdf_field":""},{"help":"Date when patient is fit to resume duties","type":"date","label":"Fitness Date to join Duties","options":[],"required":null,"pdf_field":""},{"help":"Indicate if accident caused permanent disability","type":"yes-no","label":"Has the accident resulted into loss of hand/s or foot/feet or eye/s or permanent disability of any other type which may prevent the insured from engaging in or being occupied with or giving attention to any employment or occupation whatsoever?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe the permanent disability","type":"text","label":"If yes, please give details :","options":[],"required":null,"pdf_field":""},{"help":"Signature of hospital authority","type":"signature","label":"Signature of the competent Authority of treating Hospital / Nursing Home","options":[],"required":null,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Name of hospital authority","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Designation of hospital authority","type":"text","label":"Designation:","options":[],"required":null,"pdf_field":""},{"help":"Affix official hospital seal","type":"attachment","label":"Official Seal of the Hospital:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital authorities"},{"title":"Nominee Details (In Event of Insured's Death)","fields":[{"help":"","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"H.No. :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Building/Street Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Area :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Land mark:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"","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 contact number","type":"phone","label":"Contact / Mobile No :","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age :","options":[],"required":null,"pdf_field":""},{"help":"If applicable, provide designation, employee ID and date of joining","type":"text","label":"Designation, Employee Id & Date of Joining","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to the deceased","type":"text","label":"Relationship with the deceased :","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of nominee or claimant","type":"signature","label":"Signature of the Injured Person","options":[],"required":null,"pdf_field":""}],"filled_by":"nominee"},{"title":"Declaration by Insured/Claimant/Nominee","fields":[{"help":"Date of declaration","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of declaration","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of insured, claimant or nominee","type":"signature","label":"Signature of the Injured Person","options":[],"required":true,"pdf_field":""}],"filled_by":"insured, claimant or nominee"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Choose if you want payment via EFT","type":"yes-no","label":"Would you like to opt for Electronic Fund Transfer as mode of payment ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name as per bank records","type":"text","label":"Payee Name (as per bank records):","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Payee Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account:","options":["Savings","Current","Others (specify)"],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch Name :","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch address","type":"text","label":"Address of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":null,"pdf_field":""},{"help":"Attach original cancelled cheque with signature","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the Payee.","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"attachment","label":"Please attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""},{"help":"Signature of bank account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Consent Letter for Collection of Medical Records","fields":[{"help":"Enter proposal or policy number","type":"text","label":"Proposal No. / Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter insured person's name","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Signature of claimant or insured","type":"signature","label":"Claimant / Insured Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"}],"deadlines":[],"applies_to":"Personal Accident Insurance claims","attachments":["Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee","Self-attested copy of a valid government-issued identity proof of the Claimant/Insured (mentioned in consent letter)"],"declarations":["The information given in this claim form is true, correct and complete.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this claim form does not constitute admission of liability by the company.","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes.","Declaration that particulars made by the injured person are true to the best of knowledge and belief.","Declaration that false or untrue statements will forfeit right to compensation.","Declaration accepting the amount as full discharge of company obligations and indemnifying the company against other claims.","Agreement to terms and conditions for payments through RTGS/NEFT as stated in the form."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/icici-lombard-general-insurance/386-claim-form-for-personal-accident-insurance"}