{"id":570,"title":"PERSONAL ACCIDENT/ ACCIDENTAL DEATH-COMMON CARRIER","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/travel-claim-form-b-personal-accident-ad-d-common-carrier","sha256":"85315755cadda68a7a6e25974e8a5313e8f194aa21ba6484fc4e0211ce1889c3","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for claiming personal accident or accidental death benefits under the IndusInd Travel Care Policy. It is filled by the claimant or insured person and the attending doctor.","notes":["For complete details on benefits, coverage, terms & conditions and exclusions, read the sales brochure, prospectus and policy wordings carefully before concluding sale.","Politically Exposed Persons (PEPs) are defined as per Prevention of Money Laundering Rules, 2005.","Health Care Unit contact: IndusInd General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad - 500081. Email: healthcare@indusindinsurance.com."],"title":"PERSONAL ACCIDENT/ ACCIDENTAL DEATH-COMMON CARRIER","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Accident","fields":[{"help":"Write the time of accident with am/pm","type":"text","label":"When Did The Accident Happen?","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Write time with am/pm","type":"text","label":"Time of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Death","options":[],"required":null,"pdf_field":""},{"help":"Write time with am/pm","type":"text","label":"Time of Death","options":[],"required":null,"pdf_field":""},{"help":"Location where accident happened","type":"text","label":"Location","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Please Provide The Necessary Details About The Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe loss details","type":"text","label":"Please State The Nature And Extent of Loss","options":[],"required":null,"pdf_field":""},{"help":"Enter claim amount","type":"amount","label":"Please State The Amount Claimed","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of Witness","fields":[{"help":"Select title and enter full name","type":"text","label":"WITNESS 1 Name","options":["Mr.","Ms.","Mrs."],"required":null,"pdf_field":""},{"help":"Select title and enter full name","type":"text","label":"WITNESS 2 Name","options":["Mr.","Ms.","Mrs."],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Treatment Details","fields":[{"help":"Select Yes or No","type":"choice","label":"Please Specify Whether The Insured Person Was Hospitalised For The Treatment Of Injury Due To The Accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter hospital or nursing home name","type":"text","label":"Please Provide Name Of The Hospital/Nursing Home Where The Insured Person Was Treated For The Injury Sustained Due To The Accident?","options":[],"required":false,"pdf_field":""},{"help":"Enter attending physician or surgeon name","type":"text","label":"Please Provide The Name Of Physician/Surgeon Who Attended The Insured Person During The Treatment For The Injury Sustained Due To The Accident?","options":[],"required":false,"pdf_field":""},{"help":"Describe if police were informed","type":"text","label":"Have The Police Authorities Been Informed About This Accident","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Have the Following Documents, Been Submitted? a. Copy of FIR","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"b. Death Certificate","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"c. Police Report","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"d. Post Mortem Report (in case of accident death)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Attending Doctor/Physician's Statement","fields":[{"help":"Select title and enter full name","type":"text","label":"Name Of Insured Person","options":["Mr.","Ms.","Mrs."],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Enter full address including Flat/Building/Door/Block No., Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone No.","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter fax number","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Describe accident nature and injuries","type":"text","label":"Please State Nature Of The Accident And Details Of Injuries Sustained","options":[],"required":null,"pdf_field":""},{"help":"Explain if cause and injuries match","type":"text","label":"Does The Cause Of Accident As Stated By The Insured Person Tally With The Injuries Noticed By You?","options":[],"required":null,"pdf_field":""},{"help":"Explain if injuries are only due to accident","type":"text","label":"Are The Injuries Solely Due To The Accident Or Traceable To Any Previous Injuries/Disease/Infirmities?","options":[],"required":null,"pdf_field":""},{"help":"Mention any contributing disease or injury","type":"text","label":"Was The Insured Person Suffering From Any Disease/Injury Which May Have Contributed To The Accident Or Likely To Aggravate His/Her Condition.","options":[],"required":null,"pdf_field":""},{"help":"Enter hospitalization period dates in DD/MM/YYYY format","type":"date","label":"Was The Insured Person Hospitalized? If So For What Period? From  To","options":[],"required":false,"pdf_field":""},{"help":"Describe treatment and operations","type":"text","label":"Please Provide The Details of Treatment Given And Operations Performed, If Any?","options":[],"required":null,"pdf_field":""},{"help":"State if intoxicated or drugged","type":"text","label":"Was He/She Under The Influence of Intoxicants or Drugs At The Time of Accident?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if reported","type":"text","label":"Has This Accident Been Reported To The Police Authorities? If Yes","options":[],"required":null,"pdf_field":""},{"help":"Enter police case number","type":"text","label":"Case No.","options":[],"required":false,"pdf_field":""},{"help":"Enter police station name","type":"text","label":"Police Station","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of attending doctor","type":"text","label":"Name of Attending Doctor/Physician","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signature in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Doctor to sign here","type":"signature","label":"Attending Doctor / Physician's Signature","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Regn. No.","options":[],"required":true,"pdf_field":""}],"filled_by":"Attending Doctor/Physician"},{"title":"PEP Declaration","fields":[{"help":"Select Yes or No","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe position if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please mention the name and relation and the position held by such close relative/family member.","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"AML Guidelines and General Declaration","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer/Claimant"}],"deadlines":[],"applies_to":"Personal Accident/Accidental Death claims under IndusInd Travel Care Policy","attachments":["Copy of FIR","Death Certificate","Police Report","Post Mortem Report (in case of accident death)"],"declarations":["The signer declares that if they or their close relatives become Politically Exposed Persons (PEP) in the future, they will inform the insurer.","The signer confirms that premiums are paid from legitimate sources and understands the insurer's rights under AML laws.","The signer agrees that in case of mismatch in KYC or PAN details, the insurer may issue the policy as per proposal form and the signer is responsible for consequences."],"dropped_labels":26},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"services@indusindinsurance.com","label":"Health Insurance Claims Email","level":1,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"nce Claim\nTravel Insurance Claim\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"indusind@europ-assistance.in","label":"Travel Insurance Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance App\nWebsite:\nOnline Claim Intimation\nOffline Visit:\nLocate your nearest branch\nh","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91 22 48903009","label":"Car Insurance Claim Intimation","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934189","label":"Motor Claims Helpline","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"ation.\nNeed Guidance on Car Coverage?\nTalk to Our Professional Advisors\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nSteps to Take After a Car ​Accident\nThe following steps can expedite the road accident insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934188","label":"Health Claims Helpline","level":null,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"your nearest location.\nExpert health advice you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934184","label":"Travel Claims Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"e you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation\nYour claim gets rejected when you don't gi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+912248903009","label":"Inland Travel Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"rds your registered bank account.\nHow to Contact Us For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 552","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"91-22-67347843","label":"International Travel Helpline (abroad)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 209 5522","label":"International Travel Helpline (in India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance","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/indusind-general-insurance/570-personal-accident-accidental-death-common-carrier"}