{"id":573,"title":"INDUSIND INLAND TRAVEL CARE POLICY - CLAIM FORM B","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-inland-travel-claim-form-b","sha256":"310067fe47de9496914cfefdea1f08fd6fd834d12178cbc960e91e2867cd9171","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant or policyholder to file a personal accident or accidental death and dismemberment claim under the IndusInd Inland Travel Care Policy.","notes":["All payments to the insured are made only through electronic mode as per IRDAI guidelines.","Politically Exposed Persons (PEPs) are defined as per Prevention of Money Laundering Rules, 2005.","Use the format DD/MM/YYYY for dates.","Fill mandatory fields marked with * or as stated.","Attach original or certified copies of required documents.","The Attending Doctor/Physician must fill and sign their section.","Provide complete and accurate contact details for witnesses, hospital, and physician."],"title":"INDUSIND INLAND TRAVEL CARE POLICY - CLAIM FORM B","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Accident","fields":[{"help":"","type":"text","label":"Policy No. / Certificate No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Flight No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PNR No.","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Death","options":[],"required":null,"pdf_field":""},{"help":"Write the time of death including a.m. or p.m.","type":"text","label":"Time of Death (a.m./p.m.)","options":[],"required":null,"pdf_field":""},{"help":"Provide the location where the accident occurred","type":"text","label":"Location","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident details","type":"text","label":"Please provide the necessary details about the accident","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss suffered","type":"text","label":"Please state the nature and extent of loss","options":[],"required":null,"pdf_field":""},{"help":"Enter the claim amount","type":"amount","label":"Please state the amount claimed","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of Witness","fields":[{"help":"If available, provide claim number","type":"text","label":"Claim No.","options":[],"required":null,"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":"Start date of hospitalisation (DD/MM/YYYY)","type":"date","label":"If yes, period of hospitalisation From","options":[],"required":null,"pdf_field":""},{"help":"End date of hospitalisation (DD/MM/YYYY)","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Write full name of hospital or nursing home","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":null,"pdf_field":""},{"help":"Provide full address of hospital/nursing home","type":"text","label":"Address for Communication (Flat/Building/Door/Block No., Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country)","options":[],"required":null,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Hospital mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Hospital email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Hospital fax number if any","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Full name of attending physician/surgeon","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":null,"pdf_field":""},{"help":"Provide full address of physician/surgeon","type":"text","label":"Address for Communication (Flat/Building/Door/Block No., Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country)","options":[],"required":null,"pdf_field":""},{"help":"Physician phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Physician mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Physician email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Physician fax number if any","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Provide details if police informed","type":"text","label":"Have the police authorities been informed of 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":"Age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Full address of insured person","type":"text","label":"Address (Flat/Building/Door/Block No., Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country)","options":[],"required":null,"pdf_field":""},{"help":"Phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Fax number if any","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Describe accident 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 from accident or pre-existing","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":"Provide details of 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":"Hospitalisation start date (DD/MM/YYYY)","type":"date","label":"Was the Insured person hospitalized? If so for what period? From","options":[],"required":null,"pdf_field":""},{"help":"Hospitalisation end date (DD/MM/YYYY)","type":"date","label":"To","options":[],"required":null,"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 under drugs","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":"Police case number","type":"text","label":"Case No.","options":[],"required":null,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Police Station","options":[],"required":null,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name of Attending Doctor/Physician","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address (Flat/Building/Door/Block No., Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country)","options":[],"required":null,"pdf_field":""},{"help":"Doctor's phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Doctor's mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Doctor's email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Doctor's fax number if any","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Date of signing (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Attending Doctor / Physician's Signature","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Regn. No.","options":[],"required":null,"pdf_field":""}],"filled_by":"attending doctor/physician"},{"title":"Proposer's Bank Details","fields":[{"help":"Enter bank account number","type":"text","label":"Bank Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter 9 digit MICR code","type":"text","label":"MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)","options":[],"required":true,"pdf_field":""},{"help":"Enter 11 character IFSC code","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"Tick to confirm understanding","type":"checkbox","label":"I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"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":"Provide position if applicable","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":""},{"help":"Tick to agree","type":"checkbox","label":"I hereby declare that in future if me, any of my close relatives or any of my family member attains a position of PEP then I shall confirm the same to IndusInd General Insurance Co. Ltd as a mandate.","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"AML Guidelines and General Declaration","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":""}],"deadlines":[],"applies_to":"Personal Accident/Accidental Death & Dismemberment - Common Carrier","attachments":["Copy of FIR","Death Certificate","Police Report","Post Mortem Report (in case of accident death)"],"declarations":["I understand that any refund or claim payment will be credited directly to my bank account.","I declare that if I or my close relatives become Politically Exposed Persons (PEP) in future, I will inform the insurer.","I confirm that premiums are paid from bonafide sources and not from proceeds of crime.","I understand the insurer may verify sources of funds and cancel the policy if found guilty under money laundering laws.","I consent to verification of my KYC and PAN details and accept responsibility for any mismatch consequences."],"dropped_labels":16},"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/573-indusind-inland-travel-care-policy-claim-form-b"}