{"id":427,"title":"Smart Janata Personal Accident Insurance Policy Claim Form","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/smart-janta-personal-accident-insurance-policy8c0003ff45fd68ff8a0df0055f2633fa.pdf","sha256":"89faa77bfff50256bda2c716dd9e5b00460162313ccab95f272fa62a3413d1c3","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is for filing a personal accident insurance claim by the insured person or claimant under the Smart Janata Personal Accident Insurance Policy.","notes":["Claim must be supported by medical evidence furnished by the insured at his/her expense.","Submit original hospitalization or day-care treatment documents if not submitted at discharge.","Use self-attested copy of valid government-issued identity proof with the consent letter."],"title":"Smart Janata Personal Accident Insurance Policy Claim Form","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 & 602, 6th Floor, Interface 16, New Linking Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Policy and Insured Person Details","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Date when the claim is registered","type":"date","label":"Date of registration","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Office Code","options":[],"required":null,"pdf_field":""},{"help":"Name and code of the insurance intermediary if applicable","type":"text","label":"Name & Code of Intermediary","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured person","type":"text","label":"1. Name of the Insured / Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Customer identification number","type":"text","label":"2. Customer ID","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"3. Address of the Insured / Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Current profession or occupation of the insured","type":"text","label":"4. Profession or Occupation","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under the policy","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Type of cover under the policy","type":"text","label":"Cover","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Details of Accident","fields":[{"help":"Name of the person who suffered the accident","type":"text","label":"5. Name of the insured person","options":[],"required":true,"pdf_field":""},{"help":"Date when the accident occurred","type":"date","label":"6. a) Date of the Accident","options":[],"required":true,"pdf_field":""},{"help":"Description of the accident circumstances","type":"text","label":"7. How did the Accident occur?","options":[],"required":true,"pdf_field":""},{"help":"Describe injuries and specify side if applicable","type":"text","label":"8. Nature of Injury received (if to limb or Eye state whether right or left)","options":[],"required":true,"pdf_field":""},{"help":"Type of disablement caused by the accident","type":"text","label":"9. a) Nature of disablement","options":[],"required":null,"pdf_field":""},{"help":"Surgeon's full name and address","type":"text","label":"10. Name and address of Surgeon in attendance","options":[],"required":null,"pdf_field":""},{"help":"Place and time for medical officer visit","type":"text","label":"11. Where and when can a Medical Officer of our Company visit you, if necessary?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you have other accident insurance","type":"yes-no","label":"12. a) Are you insured in any other Office or Offices granting compensation for accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if you have other similar insurance","type":"yes-no","label":"Do You have any other insurance for similar claim (either with Us or with any other insurer)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide Policy No., Policy Period, Sum Insured, Name of the insurer, Policy/product name","type":"table","label":"If yes please specify details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Declaration and Signature","fields":[{"help":"Sign to declare the truthfulness of the claim","type":"signature","label":"Signature of the Insured / Insured Person / nominee / legal representative(s)","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Address of the signer","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Witness Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person / nominee / legal representative"},{"title":"Medical Certificate","fields":[{"help":"Name of the claimant","type":"text","label":"Name of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Age of the claimant","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident and cause","type":"text","label":"1. Nature and cause of Accident","options":[],"required":true,"pdf_field":""},{"help":"Specify side of injury if applicable","type":"text","label":"2. If to eye or limb, state left or right.","options":[],"required":null,"pdf_field":""},{"help":"Confirm if injuries match the accident description","type":"yes-no","label":"3. Whether the appearance of the injuries are consistent with the account given of the accident.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Date of first medical attendance","type":"date","label":"4. Date on which you first attended claimant for this injury.","options":[],"required":true,"pdf_field":""},{"help":"Duration of total disability if any","type":"text","label":"5. Has claimant been totally prevented from attending to any portion of his/her business/occupation/normal duties? If so for how long?","options":[],"required":null,"pdf_field":""},{"help":"Details of any other illness affecting recovery","type":"text","label":"6. Is claimant suffering from any disease or illness apart from his injury and is there any illness by circumstances which may tend to retard recovery? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Current medical condition of the claimant","type":"text","label":"7. Present condition.","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature certifying the medical certificate","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Consent Letter","fields":[{"help":"Enter your proposal or policy number","type":"text","label":"Proposal No. / Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Full name of the insured","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Signature consenting to medical record collection","type":"signature","label":"Claimant / Insured Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person or claimant"}],"deadlines":[],"applies_to":"Smart Janata Personal Accident Insurance Policy claims","attachments":["Medical Evidence to support the claim","Self-attested copy of a valid government-issued identity proof of the Claimant/Insured","Original hospitalization or day-care treatment-related documents if not submitted earlier"],"declarations":["The statements made in this form are true and no information has been concealed.","If any false or fraudulent statement is made, the policy shall be void and compensation forfeited.","Consent is given to the company to verify identity/address proof through Central KYC Registry or UIDAI or other modes."],"dropped_labels":7},"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/427-smart-janata-personal-accident-insurance-policy-claim-form"}