{"id":744,"title":"CLAIM FORM - SARAL SURAKSHA BIMA, MAGMA GIL","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Claim+Form+%E2%80%93+Saral+Suraksha+Bima.pdf/36c0027f-07f0-9e66-87b3-eeb5fc531204?t=1789044393702","sha256":"bed564e3f3e37d01797f12a305d359fab7617d4ff44da086353a74e518c3da06","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant or insured person to file a claim under the Saral Suraksha Bima insurance policy with Magma General Insurance Limited.","notes":["All questions must be answered fully; incomplete forms will be returned.","If there is insufficient space, use a separate sheet and attach it.","Kindly affix official seal/stamp on the Medical Attendant’s Certificate.","Use original documents for attachments.","The issue or acceptance of this form is not an admission of liability by Magma General Insurance Limited."],"title":"CLAIM FORM - SARAL SURAKSHA BIMA, MAGMA GIL","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. The Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"Landline","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"B. Policy Details","fields":[{"help":"Policy number as per insurance documents","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Start and end date of policy coverage","type":"date","label":"Period of Insurance to","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"C. Claimant/Deceased Details","fields":[{"help":"Name of claimant or deceased","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Sex Male Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Date of birth in dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Occupation of claimant/deceased","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Relationship to the insured person","type":"text","label":"Relationship with Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"D. Accident Details","fields":[{"help":"Date when accident occurred","type":"date","label":"Date of accident (dd/mm/yy)","options":[],"required":true,"pdf_field":""},{"help":"Time of accident with am or pm","type":"text","label":"Time of accident am/pm","options":["am","pm"],"required":true,"pdf_field":""},{"help":"Whether accident happened at workplace","type":"yes-no","label":"Did it occur at work Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Where did the accident occur","options":[],"required":true,"pdf_field":""},{"help":"Description of accident circumstances","type":"text","label":"How did the accident happen","options":[],"required":true,"pdf_field":""},{"help":"Whether police report was filed","type":"yes-no","label":"Was the accident reported to Police Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Reason for not reporting to police if applicable","type":"text","label":"If not, kindly state the reasons","options":[],"required":false,"pdf_field":""},{"help":"Whether witnesses were present","type":"yes-no","label":"Are there any witnesses to the accident Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Names and contacts of witnesses","type":"text","label":"If yes, kindly provide name(s) and contact details","options":[],"required":false,"pdf_field":""},{"help":"Attach post-mortem report if yes","type":"yes-no","label":"Was Post-mortem conducted Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of injuries sustained","type":"text","label":"Describe the nature of injuries received","options":[],"required":true,"pdf_field":""},{"help":"List duties not possible due to disability","type":"text","label":"If partially disabled, kindly state the daily duties of usual occupation which cannot be performed","options":[],"required":false,"pdf_field":""},{"help":"Address for insurance representative visit","type":"text","label":"Address where a representative on behalf of Magma General Insurance Limited can visit","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"E. Hospitalization / Treatment Details","fields":[{"help":"Indicate if hospitalization occurred","type":"yes-no","label":"Whether hospitalized following the accident Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Hospital details if hospitalized","type":"text","label":"If yes, name & address of hospital","options":[],"required":false,"pdf_field":""},{"help":"Hospital admission and discharge dates","type":"date","label":"Period of hospitalization (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Treatment details","type":"text","label":"Kindly provide details of treatment prescribed","options":[],"required":false,"pdf_field":""},{"help":"Date and description of surgery if performed","type":"date","label":"Date & Nature of surgical procedure, if any (dd/mm/yy)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"F. Details of Dependent Children (For claim under Education Grant Benefit)","fields":[{"help":"Name of child dependent","type":"text","label":"Name of Dependent Child","options":[],"required":false,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age of Dependent Child","options":[],"required":false,"pdf_field":""},{"help":"Educational institution name","type":"text","label":"Name of School/College/Institute","options":[],"required":false,"pdf_field":""},{"help":"Course or education level","type":"text","label":"Education Pursuing","options":[],"required":false,"pdf_field":""},{"help":"Attach these documents for education grant claims","type":"checkbox","label":"Documents required","options":["Admission card","ID card","Last year’s Mark sheet","Letter from school, college, institute affirming he/she is studying in their organization."],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"G. Other Insurances","fields":[{"help":"Other insurer name if any","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Coverage period of other insurance","type":"text","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"Coverage details of other insurance","type":"text","label":"Coverage","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"H. Claim Amount and Medical Attendant’s Certificate","fields":[{"help":"Name of doctor certifying treatment","type":"text","label":"Doctor’s name","options":[],"required":true,"pdf_field":""},{"help":"Patient’s full name","type":"text","label":"Name of patient","options":[],"required":true,"pdf_field":""},{"help":"Hospitalization dates if applicable","type":"date","label":"Period of hospitalization (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Details of complications if any","type":"text","label":"Are there any complications which may retard the recovery","options":[],"required":false,"pdf_field":""},{"help":"Whether complications will delay recovery","type":"yes-no","label":"Will the recovery be retarded due to above Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Previous similar injury history","type":"yes-no","label":"Has the patient suffered from similar injury/disability previously Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of previous injury if yes","type":"text","label":"If yes, when, nature and duration of the","options":[],"required":false,"pdf_field":""},{"help":"Whether doctor is usual medical attendant","type":"yes-no","label":"Are you his/her usual Medical Attendant Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of other doctors consulted","type":"text","label":"Please give details of other consultations","options":[],"required":false,"pdf_field":""},{"help":"Connection to previous conditions","type":"yes-no","label":"Are the injuries connected with any previous accident, infirmity or disease Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of previous conditions if yes","type":"text","label":"If yes, please provide details","options":[],"required":false,"pdf_field":""},{"help":"Ongoing treatment status","type":"yes-no","label":"Are you still treating the patient for the injury/disability Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Hospital name if patient was admitted","type":"text","label":"If hospitalized, name of hospital","options":[],"required":false,"pdf_field":""},{"help":"Period patient was under care","type":"date","label":"While under your care and direction, how long was or will the patient be: From (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Period of total disability","type":"date","label":"a) Totally unable to perform each and every duty of his/her usual occupation (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Period of partial disability","type":"date","label":"b) Partially disabled from performing his/her usual occupation (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Check if permanent total disability applies","type":"checkbox","label":"Permanent Total Disability","options":[],"required":false,"pdf_field":""},{"help":"Check if permanent partial disability applies","type":"checkbox","label":"Permanent Partial disability","options":[],"required":false,"pdf_field":""},{"help":"Doctor’s comments on recovery","type":"text","label":"Prognosis Please comment on any additional factor that may prolong recovery from injury/disability","options":[],"required":false,"pdf_field":""},{"help":"Description of permanent disablement","type":"text","label":"Nature of disablement (in case of permanent disability)","options":[],"required":false,"pdf_field":""},{"help":"Doctor’s signature","type":"signature","label":"Signature*","options":[],"required":true,"pdf_field":""},{"help":"Doctor’s registration number","type":"text","label":"Reg.No.","options":[],"required":true,"pdf_field":""},{"help":"Doctor’s address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Doctor’s name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Date of certificate","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Doctor’s email","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Doctor’s city","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Doctor’s state","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Doctor’s postal code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Doctor’s mobile phone","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / medical attendant"},{"title":"Signature of Insured/claimant and Declaration","fields":[{"help":"Signature of claimant or insured","type":"signature","label":"Signature of Insured/claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"}],"deadlines":[],"applies_to":"Claims under Saral Suraksha Bima policy","attachments":["Post-mortem Report (if post-mortem conducted)","Admission card (for dependent children education grant claim)","ID card (for dependent children education grant claim)","Last year’s Mark sheet (for dependent children education grant claim)","Letter from school, college, institute affirming he/she is studying in their organization (for dependent children education grant claim)"],"declarations":["I authorize any hospital, physician or any other medical provider who has attended me or examined me to furnish Magma General Insurance Limited such details of my medical history/treatment as they may require.","I hereby warrant the truth of foregoing statement and sincerely declare that I have not suppressed or concealed any information that is material to this claim.","I understand that false declarations may result in Magma General Insurance Limited being able to refuse to pay a claim.","I certify that I have personally attended to the named above patient and the above statements are correct."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Magma General Insurance Limited (Claims Hub), Srinilaya Cyber Spazio Suite 101, 102, Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana – 500034","label":"Claims Hub Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.magmainsurance.com/learn-about-claims","quote":"fe takes an unexpected turn. When that moment comes, a clear and dependable claims process makes all the difference. At Magma General Insurance, our aim is to make the process simple to understand, transparent to follow, and supportive at every step. This page explains how claims work across Health, Motor and Non‑Motor policies.\nClaim is easy at Magma General Insurance.\nRegister Claim\nHealth","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customercare@magmainsurance.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"ma HDI General Insurance Company Limited) | All Rights Reserved\n| IRDAI Reg. No. 149 |\nwww.magmainsurance.com\n| E-mail:\ncustomercare@magmainsurance.com\n| Registered & Corporate Office: Equinox Business Park, Tower 3, Ambedkar Nagar, 2\nnd\nFloor, Unit Number 1B & 2B, LBS M","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 266 3202","label":"Claims Intimation Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"surance Claims - Motor & Health Insurance Claim Process - Magma Insurance - Magma\nSkip to Content\nOne-Line-Hearder-Test\n1800 266 3202\nNavigation\nCustomer Service\nSenior Citizen Services\nRoad side Assistance\nAnnual Health Check-up\nPolicy Servicing assist","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/magma-general-insurance/744-claim-form-saral-suraksha-bima-magma-gil"}