{"id":576,"title":"PERSONAL ACCIDENT - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/personal-accident-claim-form","sha256":"0c2ef2ca693910ede3bc8460c23c4b57bf9d3038816402b51d722a30e044c1d5","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to file a personal accident insurance claim with IndusInd General Insurance Company Limited.","notes":["Use original cancelled cheque in CTS 2010 format with printed account number, IFSC code, and printed name; if name is not printed, attach passbook or bank statement copy.","Attach self-attested Aadhaar card copy for Aadhaar based payment claims.","For claims above 1 lac, PAN card or Form 60 copy is mandatory; for claims below 1 lac, photo identity proof is mandatory.","Claim must be supported by medical evidence furnished by the insured at his/her expense.","The form must be submitted within 30 days of the date of loss.","The medical certificate must be filled by the treating doctor.","The document checklist is indicative; additional documents may be requested.","Fill all mandatory fields marked with *."],"title":"PERSONAL ACCIDENT - CLAIM FORM","submit":{"to":"Health Care: IndusInd General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad - 500081","how":"post or email","address":"Email: healthcare@indusindinsurance.com"},"purpose":"claim","sections":[{"title":"Policy Details and Insured Information","fields":[{"help":"Enter your policy number exactly as on your policy document.","type":"text","label":"*Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter policy start date in DD/MM/YYYY format.","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""},{"help":"Enter policy end date in DD/MM/YYYY format.","type":"date","label":"Period To","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of registration in DD/MM/YYYY format.","type":"date","label":"Date of Registration","options":[],"required":null,"pdf_field":""},{"help":"Enter your broker or agent's name.","type":"text","label":"Broker/Agent Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the broker/agent code.","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"Enter the mobile number of your agent.","type":"phone","label":"Agent Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the email ID of your agent.","type":"email","label":"Agent Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured person.","type":"text","label":"*Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter your customer ID.","type":"text","label":"*Customer ID","options":[],"required":true,"pdf_field":""},{"help":"Enter your full address including Plot No./Flat No., Building Name, Road, Area, City, Pin Code, and State.","type":"text","label":"*Address of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter your phone number.","type":"phone","label":"*Phone No.","options":[],"required":true,"pdf_field":""},{"help":"Enter your PAN number if available.","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your email address.","type":"email","label":"*E-mail Id","options":[],"required":true,"pdf_field":""},{"help":"Select your profession or occupation.","type":"choice","label":"Profession/Occupation","options":["Business","Profession","Salary","Agricultural Income","Savings","Others"],"required":null,"pdf_field":""},{"help":"Select your monthly income range.","type":"choice","label":"Monthly Income","options":["Upto  20,000","20,001 to  50,000","50,001 to  1,00,000","1,00,001 and above"],"required":null,"pdf_field":""},{"help":"Specify your profession or occupation.","type":"text","label":"4. Profession or Occupation","options":[],"required":null,"pdf_field":""},{"help":"Provide details of sum insured and table of cover as per policy.","type":"text","label":"Policy details Sum Insured Table of Cover","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Details of Accident","fields":[{"help":"Enter the name of the person injured or deceased in the accident.","type":"text","label":"5. a) Name of the Insured Person dead/injured in the accident","options":[],"required":null,"pdf_field":""},{"help":"Specify the relationship with the employee or member.","type":"text","label":"b) Relationship with the employee/member","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of the accident in DD/MM/YYYY format.","type":"date","label":"6. a) Date of accident:","options":[],"required":null,"pdf_field":""},{"help":"Enter the time of accident in HH:MM AM/PM format.","type":"text","label":"b) Time of accident:","options":[],"required":null,"pdf_field":""},{"help":"Enter the location where the accident occurred.","type":"text","label":"c) Place of accident:","options":[],"required":null,"pdf_field":""},{"help":"Provide name and address of any witness to the accident.","type":"text","label":"d) Name & address of the witness:","options":[],"required":null,"pdf_field":""},{"help":"Describe the details of the accident.","type":"text","label":"7. Particulars of the accident:","options":[],"required":null,"pdf_field":""},{"help":"Describe the injuries sustained, specifying side if applicable.","type":"text","label":"8. Nature of injury received (if to limb or eye state whether right or left)","options":[],"required":null,"pdf_field":""},{"help":"Describe the type of disablement caused by the accident.","type":"text","label":"9. a) Nature of disablement","options":[],"required":null,"pdf_field":""},{"help":"Specify the extent or percentage of disablement.","type":"text","label":"b) Extent of disablement","options":[],"required":null,"pdf_field":""},{"help":"Describe the current condition of incapacity.","type":"text","label":"d) Present state of incapacity","options":[],"required":null,"pdf_field":""},{"help":"Provide the name and address of the attending surgeon.","type":"text","label":"10. Name and address of surgeon in attendance","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance companies and coverage amounts.","type":"text","label":"b) If so state name and address of company or companies and amount of insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Policyholder Bank Details","fields":[{"help":"Enter the full name of the bank account holder with title.","type":"text","label":"13. Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"required":null,"pdf_field":""},{"help":"Enter your bank account number.","type":"text","label":"14. Bank Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select the type of bank account.","type":"choice","label":"15. Account:","options":["Saving","Current"],"required":null,"pdf_field":""},{"help":"Enter the name of your bank.","type":"text","label":"16. Name of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter the branch name of your bank.","type":"text","label":"17. Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter the 9-digit MICR code from your cheque leaf.","type":"text","label":"18. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank):","options":[],"required":null,"pdf_field":""},{"help":"Enter the 11-character IFSC code from your cheque leaf.","type":"text","label":"19. IFSC Code (11 character code appearing on your cheque leaf):","options":[],"required":null,"pdf_field":""},{"help":"Enter your Aadhaar number and attach a self-attested copy.","type":"text","label":"AADHAAR BASED PAYMENT (FOR REIMBURSEMENT CLAIMS) Aadhaar Card No.:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Declaration by Insured/Claimant","fields":[{"help":"Sign the form to declare the information is true and correct.","type":"signature","label":"Signature of Insured Person/Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of signing in DD/MM/YYYY format.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Medical Certificate (To be filled by Treating Doctor)","fields":[{"help":"Enter the claimant's full name.","type":"text","label":"1. a) Name of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's age.","type":"number","label":"b) Age","options":[],"required":true,"pdf_field":""},{"help":"Describe the nature and cause of the accident.","type":"text","label":"2. a) Nature and cause of accident","options":[],"required":true,"pdf_field":""},{"help":"Specify if injury is to left or right eye or limb.","type":"text","label":"b) If to eye or limb, state left or right","options":[],"required":true,"pdf_field":""},{"help":"Confirm if injuries match the accident description.","type":"yes-no","label":"c) Whether the appearance of the injuries are consistent with the account given of the accident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify duration of total disablement from work.","type":"text","label":"4. Has claimant been totally prevented from attending to any portion of his business? If so, for how long?","options":[],"required":true,"pdf_field":""},{"help":"Provide details of any other illness affecting recovery.","type":"text","label":"5. 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":true,"pdf_field":""},{"help":"Describe the current medical condition of the claimant.","type":"text","label":"6. Present condition","options":[],"required":true,"pdf_field":""},{"help":"Estimate duration of total and partial disablement.","type":"text","label":"7. How long from the happening of the accident do you consider a) Total disablement will last b) Partial disablement will last","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"PEP and AML Declarations","fields":[{"help":"Indicate if you are a PEP as defined under PMLA rules.","type":"yes-no","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify the position held if you are a PEP.","type":"text","label":"If yes, please mention the position held","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any close relative or family member is a PEP.","type":"yes-no","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of the relative who is a PEP.","type":"text","label":"If yes, please mention the name and relation and the position held","options":[],"required":null,"pdf_field":""},{"help":"Sign to confirm AML declarations.","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/proposer"}],"deadlines":["Please submit the completely filled claim form within thirty days from the date of loss along with the relevant claim documents."],"applies_to":"Group Personal Accident Policy and Individual Personal Accident Policy","attachments":["Original/Attested copy of Death Certificate","Attested copy of Post Mortem Examination report","Copy of Medico Legal Certificate from hospital (in case of accident)","Copy of Photo ID proof of Insured person (Employee/Member ID card)","Attested copy of FIR of local police station or Detailed Police Information note or Inquest Panchnama / Spot Panchnama (if applicable)","Original Cancelled Cheque in CTS 2010 format (Printed account number, IFSC code, Printed name) or scanned copy of 1st page of passbook or authorized bank statement","For claimed amount above 1 lac self attested copy of PAN Card / Form 60 of Insured","For claimed amount below 1 lac copy of Photo identity proof (PAN Card / Form 60, Aadhaar Card, Voter ID etc.)","Complete treatment record like Discharge summary, Consultation papers with supporting Investigation reports like X-ray / MRI etc. (for injury claims)","Coloured and clear photograph of Disabled person showing the disability (for PTD & PPD claims)","Leave Certificate from the Employer mentioning the leave dates (for TTD claims)","Medical Certificate confirming the Disability period and the probable date to resume duty/service (for TTD claims)","Self attested Aadhaar card copy (for Aadhaar based payment)"],"declarations":["The details given above are true and correct to the best of my belief and knowledge.","If any information is found incorrect, all rights under the policy will be forfeited.","I agree to provide additional information if required and indemnify the company for any loss due to misstatement.","I agree not to receive any rebate other than that mentioned in the published prospectus as per Insurance Act provisions.","I confirm that all premiums have been/will be paid from bona fide sources and not from proceeds of crime.","The company has the right to call for documents to establish sources of funds.","The company may cancel the insurance contract if found guilty under money laundering laws.","I consent to verification of my KYC and PAN details and accept responsibility for any mismatch consequences.","I will inform the company if I or any close relative attains a position of Politically Exposed Person (PEP)."],"dropped_labels":8},"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/576-personal-accident-claim-form"}