{"id":575,"title":"INDUSIND INLAND TRAVEL CARE POLICY - CLAIM FORM A","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-a","sha256":"853aa54f8ee06ecc90cac4b5d79017595319c8e5c266db4d8632a398bfd77482","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to claim reimbursement for hospitalization, emergency medical expenses, repatriation of remains, or emergency evacuation under the IndusInd Inland Travel Care Policy.","notes":["Use the sales brochure, prospectus and policy wordings for complete details on benefits, coverage, terms and exclusions.","All payments to the insured are made only through electronic mode as per IRDAI guidelines.","Fill dates in DD/MM/YYYY format.","Provide full addresses and contact details wherever requested.","The Attending Physician's Statement must be completed and signed by the treating doctor.","PEP means Politically Exposed Person as defined under PMLA Rules.","Ensure all mandatory fields marked with * are filled.","Original bills and documents should be attached as per policy requirements (not explicitly listed here)."],"title":"INDUSIND INLAND TRAVEL CARE POLICY - CLAIM FORM A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Hospitalization Expenses / Emergency Medical Expenses","fields":[{"help":"","type":"text","label":"Policy No./Certificate No.","options":[],"required":null,"pdf_field":""},{"help":"Describe the disease or illness","type":"text","label":"In case of disease / illness Please provide the details of the disease/illness","options":[],"required":null,"pdf_field":""},{"help":"Explain the cause of the disease or illness","type":"text","label":"Please provide the cause of the disease / illness","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of onset of disease / illness","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident details","type":"text","label":"In case of accident Please provide the details of the accident","options":[],"required":null,"pdf_field":""},{"help":"Explain the cause of the accident","type":"text","label":"Please provide the cause of the accident","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of the accident","options":[],"required":null,"pdf_field":""},{"help":"Specify the location of the accident","type":"text","label":"Place of the accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Please specify whether the Patient/Insured person was hospitalized for treatment of disease/illness/injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter start and end dates of hospitalization","type":"date","label":"If yes, period of Hospitalization/Treatment done for disease/illness/injury From DD/MM/YYYY To DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"Describe the treatment given","type":"text","label":"Nature of Treatment done for disease/illness/injury","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital or nursing home name","type":"text","label":"Name of the hospital/Nursing Home where treatment of the disease/illness/injury was given","options":[],"required":null,"pdf_field":""},{"help":"Provide full address of the hospital/nursing home","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":"Hospital phone number","type":"phone","label":"Telephone No.","options":[],"required":null,"pdf_field":""},{"help":"Hospital fax number if any","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Name of the doctor who treated the patient","type":"text","label":"Name of the Attending Doctor / Physician Dr.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's full 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":"If claim number is assigned, provide it","type":"text","label":"Claim No.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant / insured person"},{"title":"Additional Medical Details and Expenses","fields":[{"help":"Contact telephone number","type":"phone","label":"Telephone No.","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Fax number if any","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Was the disease/illness/injury caused and/or aggravated by any pre-existing condition/disease/illness/injury?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if pre-existing condition contributed","type":"text","label":"If Yes,","options":[],"required":false,"pdf_field":""},{"help":"Describe treatment details","type":"text","label":"Has the Patient/insured person been treated for the disease/illness/injury? Please specify the necessary details of the treatment received","options":[],"required":null,"pdf_field":""},{"help":"Name of the consulting doctor","type":"text","label":"Name of the Consulted Physician Dr.","options":[],"required":null,"pdf_field":""},{"help":"Full address of the consulting physician","type":"text","label":"Address of the Consulted Physician Flat/Building/Door/Block No. Road / Street / Sector Area Taluka/Village/District/City Pin Code State Country","options":[],"required":null,"pdf_field":""},{"help":"Consulting physician's mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Consulting physician's fax number","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Consulting physician's phone number","type":"phone","label":"Telephone Number of the Consulted Physician","options":[],"required":false,"pdf_field":""},{"help":"List current prescription medicines","type":"text","label":"Please specify the names of the prescription medicines that the Patient/Insured person is presently taking, if any","options":[],"required":false,"pdf_field":""},{"help":"Provide details of treatment expenses including dates, charges, paid and outstanding amounts","type":"table","label":"Please provide the details of the expenses related to your treatment Detail of Expenses In/Out Patient Charges (Currency) Rupees From To Paid Outstanding Total Due","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant / insured person"},{"title":"Repatriation of Remains / Emergency Evacuation","fields":[{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Departure","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Arrival","options":[],"required":null,"pdf_field":""},{"help":"Flight number for evacuation or repatriation","type":"text","label":"Flight No.","options":[],"required":false,"pdf_field":""},{"help":"Start date of flight segment","type":"date","label":"From","options":[],"required":false,"pdf_field":""},{"help":"End date of flight segment","type":"date","label":"To","options":[],"required":false,"pdf_field":""},{"help":"Passenger Name Record number","type":"text","label":"PNR No.","options":[],"required":false,"pdf_field":""},{"help":"Explain cause leading to evacuation","type":"text","label":"In case of a claim for emergency evacuation: Cause of disease/illness/injury leading to evacuation","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of injury or commencement of disease/illness","options":[],"required":null,"pdf_field":""},{"help":"Place of injury or disease commencement","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Cause of death","type":"text","label":"In case of a claim for repatriation of remains/funeral expenses: Cause of Death","options":[],"required":false,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Death","options":[],"required":false,"pdf_field":""},{"help":"Place where death occurred","type":"text","label":"Place of Death","options":[],"required":false,"pdf_field":""},{"help":"Provide date, place, amount and total due for expenses","type":"table","label":"Please provide the details of the expenses related to the repatriation/funeral/evacuation Detail of Expenses incurred Date Place Amount Total Due","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant / insured person"},{"title":"Attending Physician's Statement","fields":[{"help":"Patient/Insured Person's name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Patient's age in years","type":"number","label":"Age Yrs.","options":[],"required":null,"pdf_field":""},{"help":"Select patient's sex","type":"choice","label":"Sex","options":["M","F"],"required":null,"pdf_field":""},{"help":"Patient's full 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":"Patient's phone number","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Patient's fax number if any","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Patient's email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Date and time of first consultation","type":"text","label":"Please specify the date & time when the Patient/Insured Person first contacted you","options":[],"required":null,"pdf_field":""},{"help":"Describe diagnosis and treatment","type":"text","label":"Please provide the details of the diagnosis and treatment given for the disease/illness/ injury","options":[],"required":null,"pdf_field":""},{"help":"List medical investigations performed","type":"text","label":"Please provide the details of medical investigation done, if any","options":[],"required":false,"pdf_field":""},{"help":"Confirm if cause matches injuries","type":"text","label":"In case of accidental injury Does the cause of accident as stated by the Patient/Insured Person tally with the injuries noticed by you?","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Was the Patient/Insured Person suffering from any condition/disease/illness/injury which may have contributed to the accident or likely to aggravate his/her condition","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of contributing/aggravating condition","type":"text","label":"If yes, please specify the necessary details","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Was the Patient/Insured Person under the influence of alcohol or intoxicants or drugs at the time of accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of influence of alcohol or drugs","type":"text","label":"If yes, please specify the necessary details","options":[],"required":false,"pdf_field":""},{"help":"Date symptoms appeared","type":"text","label":"In case of disease/illness When did the Patient/ Insured Person's symptoms first appear?","options":[],"required":false,"pdf_field":""},{"help":"Cause of disease or illness","type":"text","label":"Please specify the cause of the disease/illness","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Was the disease/illness caused and/or aggravated due to any pre-existing condition/ disease/illness/injury ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of pre-existing condition","type":"text","label":"If yes, please give the necessary details","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Is the condition due to pregnancy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Yes or No and details if yes","type":"text","label":"Was the Patient/Insured Person hospitalized for the treatment of the disease/illness/injury?","options":[],"required":false,"pdf_field":""},{"help":"Hospitalization start and end dates","type":"date","label":"If yes, please provide the following details Period of Hospitalization From DD/MM/YYYY To DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"Hospital or nursing home name","type":"text","label":"Name of Hospital/ Nursing Home where treatment of the disease/illness/injury was given","options":[],"required":false,"pdf_field":""},{"help":"Hospital address","type":"text","label":"Address Flat/Building/Door/Block No. Road / Street / Sector Area Taluka/Village/District/City Pin Code State Country","options":[],"required":false,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Hospital fax number","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Attending Doctor / Physician Dr.","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Doctor's phone number","type":"phone","label":"Telephone No.","options":[],"required":false,"pdf_field":""},{"help":"Doctor's mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Doctor's email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Doctor's fax number","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Attending Doctor's/Physician's Signature","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"attending doctor / physician"},{"title":"Proposer's Bank Details","fields":[{"help":"Select title and provide full name","type":"choice","label":"Name of the Bank Account Holder","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Provide bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account","options":["Saving","Current"],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"9 digit MICR code from cheque","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":"11 character IFSC code from cheque","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"Mandatory consent for electronic payment","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":["I agree"],"required":true,"pdf_field":""}],"filled_by":"proposer / insured person"},{"title":"PEP Declaration","fields":[{"help":"","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify position if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of relative who is PEP","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":"Sign to declare PEP information","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer / insured person"}],"deadlines":[],"applies_to":"IndusInd Inland Travel Care Policy claims related to hospitalization expenses, emergency medical expenses, repatriation of remains, and emergency evacuation","attachments":[],"declarations":["I understand that any refund or payment claims will be credited only to the bank account provided.","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 KYC and PAN verification and accept responsibility for any mismatches in details provided."],"dropped_labels":1},"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/575-indusind-inland-travel-care-policy-claim-form-a"}