{"id":580,"title":"INDUSIND FINANCIAL PROTECTION PERSONAL ACCIDENT POLICY - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-financial-protection-personal-accident-policy-claim-form","sha256":"7e59e748410be095daa6dec86af69356dccf6c975de1be3a989ed2b903d6b8b8","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for filing a personal accident insurance claim under the IndusInd Financial Protection Personal Accident Policy. It is filled by the insured person or claimant.","notes":["Use original bills and relevant claim documents.","Attach original cancelled cheque and PAN card copy for bank details verification.","Attach self-attested Aadhaar card copy if opting for Aadhaar based payment.","All payments to insured are made only through electronic mode as per IRDAI guidelines.","Fill all mandatory fields marked with *.","The medical certificate must be filled by the treating doctor at the claimant's expense.","The form must be submitted within 30 days of the date of loss."],"title":"INDUSIND FINANCIAL PROTECTION PERSONAL ACCIDENT POLICY - CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"","type":"text","label":"*Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter start date of policy period","type":"date","label":"Period From","options":[],"required":true,"pdf_field":""},{"help":"Enter end date of policy period","type":"date","label":"Period To","options":[],"required":true,"pdf_field":""},{"help":"Date when claim is registered","type":"date","label":"Date of Registration","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Area Office Code/ Service Centre Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Broker/Agent Name","options":[],"required":null,"pdf_field":""},{"help":"Broker/Agent code","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"Select title and enter full name","type":"text","label":"*Name of the Insured","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Customer identification number","type":"text","label":"*Customer ID","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address including Plot No./Flat No., Building name, Road, Area, City, State, Pin Code","type":"text","label":"*Address of the Insured","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"*Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"*Phone No.","options":[],"required":true,"pdf_field":""},{"help":"12 digit Aadhaar number","type":"text","label":"Aadhaar (UIDAI) No.","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN No.","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail Id","options":[],"required":false,"pdf_field":""},{"help":"Select applicable occupation","type":"choice","label":"Profession/Occupation","options":["Business","Profession","Salary","Agricultural Income","Savings","Others"],"required":false,"pdf_field":""},{"help":"Select 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":false,"pdf_field":""},{"help":"Loan account number if applicable","type":"text","label":"Loan A/C No.","options":[],"required":false,"pdf_field":""},{"help":"Select the type of claim","type":"choice","label":"Claim Pertains to","options":["Accidental death","PTD","PPD","TTD","Broken Bones","Modification of Residence/vehicle","Education Grant","Burns"],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Accident","fields":[{"help":"Full name of injured or deceased insured person","type":"text","label":"Name of the Insured Person dead/injured in the accident","options":[],"required":false,"pdf_field":""},{"help":"Relationship to policyholder","type":"text","label":"Relationship with the employee/member","options":[],"required":false,"pdf_field":""},{"help":"Identification number and relation to employee/member","type":"text","label":"*Employee/member identification no. Self/Spouse/Children","options":[],"required":true,"pdf_field":""},{"help":"Date when accident occurred","type":"date","label":"Date of accident","options":[],"required":false,"pdf_field":""},{"help":"Time when accident occurred","type":"text","label":"Time of accident","options":[],"required":false,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of accident","options":[],"required":false,"pdf_field":""},{"help":"Details of any witness to the accident","type":"text","label":"Name & address of the witness","options":[],"required":false,"pdf_field":""},{"help":"Describe how the accident happened","type":"text","label":"Particulars of the accident","options":[],"required":false,"pdf_field":""},{"help":"Describe injuries and specify side if applicable","type":"text","label":"Nature of injury received (if to limb or eye state whether right or left)","options":[],"required":false,"pdf_field":""},{"help":"Describe type of disablement","type":"text","label":"Nature of disablement","options":[],"required":false,"pdf_field":""},{"help":"Describe severity or percentage of disablement","type":"text","label":"Extent of disablement","options":[],"required":false,"pdf_field":""},{"help":"Current condition of the claimant","type":"text","label":"Present state of incapacity","options":[],"required":false,"pdf_field":""},{"help":"Surgeon's contact details","type":"text","label":"Name and address of surgeon in attendance","options":[],"required":false,"pdf_field":""},{"help":"Provide convenient time and place for medical visit","type":"text","label":"Where and when can a Medical Officer of this Company visit you, if necessary?","options":[],"required":false,"pdf_field":""},{"help":"Details if claim is for modification expenses","type":"text","label":"Modification of Residence / Vehicle details","options":[],"required":false,"pdf_field":""},{"help":"Details of children for education grant claim","type":"text","label":"Education Grant: Name of Child 1 & Age, Name of Child 2 & Age","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you insured in any other office or offices of the Company or any other company, granting compensation for accident?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of other insurance policies if any","type":"text","label":"If so state name and address of company or companies and amount of insurance","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Policyholder Bank Details","fields":[{"help":"Select title and enter full name","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account","options":["Saving","Current"],"required":false,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":false,"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":false,"pdf_field":""},{"help":"11 character IFSC code from cheque","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":false,"pdf_field":""},{"help":"Mandatory as per IRDAI for electronic payments","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":""},{"help":"Enter Aadhaar number and attach self-attested copy","type":"text","label":"AADHAAR BASED PAYMENT (FOR REIMBURSEMENT CLAIMS) Aadhaar Card No.","options":[],"required":false,"pdf_field":""},{"help":"Consent for Aadhaar linked payment","type":"checkbox","label":"I wish to collect claim reimbursement directly in my Bank account linked with my aforementioned Aadhaar Card.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declarations and Signatures","fields":[{"help":"Sign to declare correctness of information","type":"signature","label":"Signature of Insured Person/Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant and witness"},{"title":"Medical Certificate (To be filled by Treating Doctor)","fields":[{"help":"Full name of claimant","type":"text","label":"Name of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Age of claimant","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Describe accident and injuries","type":"text","label":"Nature and cause of accident","options":[],"required":true,"pdf_field":""},{"help":"Specify side of injury","type":"text","label":"If to eye or limb, state left or right","options":[],"required":true,"pdf_field":""},{"help":"Confirm consistency of injuries with accident description","type":"yes-no","label":"Whether the appearance of the injuries are consistent with the account given of the accident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Date of first medical attendance","type":"date","label":"Date on which you first attended claimant for this injury","options":[],"required":true,"pdf_field":""},{"help":"Duration of total disablement","type":"text","label":"Has claimant been totally prevented from attending to any portion of his business? If so, for how long?","options":[],"required":true,"pdf_field":""},{"help":"Details of other illnesses if any","type":"text","label":"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":"Current medical condition","type":"text","label":"Present condition","options":[],"required":true,"pdf_field":""},{"help":"Estimated duration of disablement","type":"text","label":"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 Declaration","fields":[{"help":"","type":"yes-no","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Position held if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of family member 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":""}],"filled_by":"claimant"},{"title":"AML Guidelines and General Declaration","fields":[{"help":"Sign to confirm AML declarations","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":["Submit the completely filled claim form within thirty days from the date of loss along with the relevant claim documents"],"applies_to":"IndusInd Financial Protection Personal Accident Policy claims","attachments":["Original cancelled cheque","Copy of PAN card","Self attested Aadhaar card copy (if Aadhaar based payment is opted)","Relevant claim documents as per policy"],"declarations":["The details given are true and correct to the best of my knowledge and belief.","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.","I understand that any refund or claim payment will be credited only to my bank account electronically.","I declare that premiums have been paid from bonafide sources and no proceeds of crime are involved.","I understand the company may call for documents to establish source of funds.","I understand the company can cancel the insurance contract if found guilty under money laundering laws.","I agree to notify the company if I or my close relatives become Politically Exposed Persons (PEPs).","I consent to KYC and PAN verification and accept responsibility for any mismatch consequences."],"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/580-indusind-financial-protection-personal-accident-policy-claim-form"}