{"id":586,"title":"INDUSIND PERSONAL ACCIDENT 360 SHIELD - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-personal-accident-360shield-claim-form","sha256":"f74dbc1a1f7f29abd29c80b08abf5c7b31a2d40a1ed562f4d7b24d4f6203c191","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to file a claim under the IndusInd Personal Accident 360Shield insurance policy.","notes":["Fill the form in BLOCK LETTERS.","Answer all questions completely; attach additional sheets if space is insufficient.","Attach original bills, receipts, and payment slips.","Doctor's report is mandatory for Accident & Sickness claims.","All payments to insured are made only through electronic mode as per IRDAI guidelines.","PEP means individuals entrusted with prominent public functions as defined under PMLA Rules."],"title":"INDUSIND PERSONAL ACCIDENT 360 SHIELD - CLAIM FORM","submit":{"to":"IndusInd General Insurance Company Limited, Claims and Care management, No. 1-89/3/B/40 to 42/KS/301-302, 3rd Floor, Krishe Block, Near Durgam Cheruvu Metro Station, Krishe Sapphire, Madhapur, Hyderabad, Telangana – 500081","how":"post or email","address":"healthcare@indusindinsurance.com"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"Fill in full name in block letters","type":"text","label":"Name of the Insured","options":["Mr.","Mrs.","Ms."],"required":null,"pdf_field":""},{"help":"Fill in full address including pin code, state, country","type":"text","label":"Address for Communication","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Select the source of your funds","type":"choice","label":"Source of fund","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":"Enter your PAN number","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does Insured have any other insurance coverage out of India?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"If yes, please provide the details","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurance company if applicable","type":"text","label":"Name of the Insurance Company","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance if applicable","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policy if applicable","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of other policy if applicable","type":"date","label":"Policy Start Date","options":[],"required":false,"pdf_field":""},{"help":"End date of other policy if applicable","type":"date","label":"Policy End Date","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Details of Patient/Insured Person","fields":[{"help":"Fill in full name in block letters","type":"text","label":"Name of the Patient/Insured Person","options":["Mr.","Mrs.","Ms."],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Sex:","options":["M","F"],"required":null,"pdf_field":""},{"help":"Fill in full address including pin code, state, country","type":"text","label":"Address for Communication","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA number if available","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA address if available","type":"text","label":"ABHA Address","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Claim Details","fields":[{"help":"Select the type of claim","type":"choice","label":"Type of Claim","options":["Accidental Death (AD)","Permanent Total Disablement (PTD)","Permanent Partial Disablement (PPD)","Repatriation of Mortal Remains and Funeral Expenses"],"required":null,"pdf_field":""},{"help":"Enter date of accident in DD/MM/YYYY format","type":"date","label":"Date of accident:","options":[],"required":null,"pdf_field":""},{"help":"Provide a brief description of the loss or accident","type":"text","label":"Brief description of loss","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has he Emergency Assistance Service Provider been intimated?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide reference number if Emergency Assistance was intimated","type":"text","label":"If Yes, please provide the reference number","options":[],"required":false,"pdf_field":""},{"help":"Enter passport number if applicable","type":"text","label":"Passport No.","options":[],"required":false,"pdf_field":""},{"help":"Select all covers being claimed","type":"checkbox","label":"Select the appropriate cover which is being claimed","options":["Temporary Total Disablement (TTD)","Hospitalization and related Covers","Accidental Hospitalization","Inpatient Treatment","Day Care Procedure","Domestic Road Ambulance","Pre-hospitalization","Post-hospitalization","Cumulative Bonus for Accidental Hospitalization","Unlimited Reinstatement of Accidental Hospitalization Limit","Companion Cover","Post-Hospitalization Physiotherapy","Blood Transfusion expenses","Transportation of Imported Medicines","Domiciliary Care","Daily Hospital Cash","Accidental OPD","Enhanced Covers","Burns","Broken Bones/Fracture","Coma","Head or Spine Injury","Miscarriage","Emergency Evacuation (Air Ambulance)","Health and Wealth Being Covers","Convalescence","Modification of home or vehicle","Rehabilitation","Trauma Counselling","Medical equipment","Reconstructive Surgery","Travel Covers (Bundle)","Enhanced Overseas Travel Cover","Compassionate visit","Trip Cancellation","Event Cancellation","Extended Hotel Stay","Family Shield","Multi Member Death or Disability","Parental Care","Educational Grant","Loan Protector","EMI Protection","Caregiver Cover","Renewal Premium","Personal Shield (Bundle)","Personal effects cover","Payment Card Protection","Assistance Services:","Adventure Sports","Cumulative Bonus"],"required":null,"pdf_field":""},{"help":"Enter name of treating doctor","type":"text","label":"In case of Illness/In-patient Treatment - Name of Treating Physician/Doctor:","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Name of the Hospital:","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital address","type":"text","label":"Hospital Address:","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital registration number","type":"text","label":"Registration Number:","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital contact number","type":"phone","label":"Contact Number:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claimant's Bank Details","fields":[{"help":"Fill in full name in block letters","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"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 bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""},{"help":"Enter 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":null,"pdf_field":""},{"help":"Enter 11 character IFSC code from cheque","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"PEP Declaration","fields":[{"help":"Select Yes or No","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide position held if PEP","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":null,"pdf_field":""},{"help":"Provide details if any close relative 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":"Declarations and Signature","fields":[{"help":"Sign the form","type":"signature","label":"Proposer’s Signature *","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Claims under IndusInd Personal Accident 360Shield policy","attachments":["All bills, receipts, payment card slips pertaining to your claim","Doctor's Report as per format (mandatory for Accident & Sickness Section)"],"declarations":["The information provided is true and any false statement will forfeit claim rights.","Authorization for hospital, physician or others to provide medical information to the company.","Refunds or payments will be credited only to the bank account provided.","If a Politically Exposed Person (PEP) status changes, it must be reported to the insurer.","Premiums are paid from bona fide sources and not from proceeds of crime.","The company may verify KYC and PAN details and cancel contract if found guilty under money laundering laws.","Signature authentication via OTP creates a legally binding agreement."],"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/586-indusind-personal-accident-360-shield-claim-form"}