{"id":579,"title":"INDUSIND CRITICAL ILLNESS POLICY - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-critical-illness-claim-form","sha256":"82432bad98d2596d8cb2897135b5306eb4252647820b616236bac4cf25316810","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or policyholder to claim benefits under the IndusInd Critical Illness Policy after contracting a critical illness or undergoing surgery.","notes":["Fill the form in BLOCK LETTERS.","Answer all questions completely.","Attach original cancelled cheque and PAN card copy for bank details verification.","Use self-attested copies for Aadhaar and PAN card.","The list of documents is indicative; additional documents may be requested.","Payments will be made only through electronic mode as per IRDAI guidelines."],"title":"INDUSIND CRITICAL ILLNESS POLICY - CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Person Details","fields":[{"help":"Select title and enter full name in BLOCK LETTERS","type":"text","label":"*Name of the Insured (In whose name the policy is issued)","options":[],"required":true,"pdf_field":""},{"help":"Enter full address including Plot/Flat No., Building Name, Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country","type":"text","label":"*Address Of The Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"*Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"*Telephone","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"*Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter Aadhaar or VID number if available","type":"text","label":"Aadhaar (UIDAI) No./VID No.","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number if available","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"*Email","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"Profession/Occupation","options":["Business","Profession","Salary","Agricultural Income","Savings","Others"],"required":null,"pdf_field":""},{"help":"Select one","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":""}],"filled_by":"policyholder or insured person"},{"title":"Insured Person for Claim","fields":[{"help":"Enter full name","type":"text","label":"*Name of the Insured Person (In respect of whom the claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to policyholder","type":"text","label":"Relationship With The Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Present Completed Age","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured person"},{"title":"Policy Details","fields":[{"help":"Enter full policy number","type":"text","label":"*Policy No. (In Full)","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates (DD/MM/YYYY)","type":"date","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter name if applicable","type":"text","label":"Agent/Sub Agent Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Agent Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Agent Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Illness and Treatment Details","fields":[{"help":"Describe illness, injury or surgery","type":"text","label":"Nature of disease/illness contracted, injury sustained or surgery performed?","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the disease/illness contracted or surgery performed due to any accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide accident details if applicable","type":"text","label":"If YES, please provide the details of accident","options":[],"required":null,"pdf_field":""},{"help":"Enter date (DD/MM/YYYY)","type":"date","label":"Date on which you first visited a doctor with complaints related to this illness/injury.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name and address including Plot/Flat No., Building Name, Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country, Telephone, Mobile, Email, Fax, Qualification, Registration No.","type":"text","label":"Name and Address of the attending Medical Practitioner","options":[],"required":null,"pdf_field":""},{"help":"Provide treatment details with dates","type":"text","label":"Please give details of the treatment you have received including dates of out patient or inpatient treatment","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have any of your blood relatives suffered from similar or related illness?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If YES, give details of when it was initially diagnosed","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you been hospitalized?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full hospital address including Plot/Flat No., Building Name, Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country, Telephone, Mobile, Email, Fax","type":"text","label":"If YES, Name & Address of Hospital/Nursing Home","options":[],"required":null,"pdf_field":""},{"help":"Enter date (DD/MM/YYYY)","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter date (DD/MM/YYYY)","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is this the first claim under this Policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide previous claim details if applicable","type":"text","label":"If NO, Please Quote Previous Claim Number And Details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Proposer's Bank Details","fields":[{"help":"Select title and enter full name","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Ms.","Mrs."],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account:","options":["Saving","Current"],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch","options":[],"required":null,"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":null,"pdf_field":""},{"help":"Enter 11 character IFSC code","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":null,"pdf_field":""},{"help":"Confirm understanding of 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":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Aadhaar Based Payment (For Reimbursement claims)","fields":[{"help":"Enter Aadhaar number and attach self-attested copy","type":"text","label":"Aadhaar Card No.:","options":[],"required":null,"pdf_field":""},{"help":"Tick if you want claim credited to Aadhaar linked bank account","type":"checkbox","label":"I wish to collect claim reimbursement directly in my Bank account linked with my aforementioned Aadhaar Card.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Declarations and Signature","fields":[{"help":"Enter date of signing (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured Person","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"PEP Declaration","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide position if applicable","type":"text","label":"If yes, please mention the position held","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","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 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":null,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"Critical Illness claims under IndusInd Critical Illness Policy","attachments":["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","Copy of PAN card (self attested) if claim amount above 1 lac","Photo identity proof (PAN Card/Form 60, Aadhaar Card, Voter ID etc.) if claim amount below 1 lac","Self attested Aadhaar card copy (if opting for Aadhaar based payment)","Complete treatment record like Discharge summary, Consultation papers with supporting Investigation reports like Histopathology Reports /Xray/MRI etc.","Complete First and Post Consultation Papers","Copy of Photo ID proof of Insured person"],"declarations":["The details given are true and correct to the best of my knowledge and belief.","If any information is found incorrect, all rights under the policy will be forfeited.","I agree to provide additional information if required.","I indemnify and hold harmless the Company for any loss arising from misstatements in this form.","I agree not to receive any rebate other than that mentioned in the published prospectus as per Insurance Act provisions.","If I or my close relatives become Politically Exposed Persons (PEP) in future, I will inform the company.","I understand that the company will verify my KYC and PAN details and I accept responsibility for any mismatch consequences."],"dropped_labels":0},"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/579-indusind-critical-illness-policy-claim-form"}