{"id":746,"title":"CLAIM FORM - JANATA PERSONAL ACCIDENT","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Claim+Form+-+Janata+Personal+Accident.pdf/f787e4d1-e401-0333-0d52-ff0160751ef5?t=1789044397222","sha256":"edd824b635cf59968579d894f6941868570702503ca4f39f76ff3ac7cd6920a3","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to file a personal accident insurance claim with Magma General Insurance Limited.","notes":["All questions must be answered fully; use a separate sheet if space is insufficient.","Incomplete or blank sections will cause the form to be returned for completion.","Kindly affix official seal/stamp on Medical Attendant’s Certificate.","Issue of this Claim Form is not to be taken as an Admission of Liability."],"title":"CLAIM FORM - JANATA PERSONAL ACCIDENT","submit":{"to":"Magma General Insurance Limited","how":"post / e-mail / upload","address":"Registered Office: Equinox Business Park, Tower 3, Ambedkar Nagar, 2nd Floor, Unit Number 1B & 2B, LBS Marg, Kurla (West), Mumbai - 400070, Maharashtra, India; E-mail: customercare@magmainsurance.com"},"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:","options":[],"required":true,"pdf_field":""},{"help":"Include area code","type":"phone","label":"Phone:","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of insured","type":"phone","label":"Mobile:","options":[],"required":true,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"B. POLICY DETAILS","fields":[{"help":"If known","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Policy number as per insurance documents","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Start date of policy coverage","type":"date","label":"Period of Insurance : From","options":[],"required":true,"pdf_field":""},{"help":"End date of policy coverage","type":"date","label":"To","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"C. CLAIMANT/DECEASED DETAILS","fields":[{"help":"Name of claimant or deceased","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Sex","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Date of birth of claimant/deceased","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Current occupation","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":""},{"help":"Date when accident occurred","type":"date","label":"Date of accident","options":[],"required":true,"pdf_field":""},{"help":"Time of accident with am or pm","type":"text","label":"Time of accident","options":["am","pm"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Did it occur at work?","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":"Brief description of accident circumstances","type":"text","label":"How did the accident happen?","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the accident reported to Police?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain why accident was not reported","type":"text","label":"If not, kindly state the reasons","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are there any witnesses to the accident?","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":"","type":"yes-no","label":"Was Post-mortem conducted?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach post-mortem report if applicable","type":"attachment","label":"If yes, kindly attach a copy of the Report","options":[],"required":false,"pdf_field":""},{"help":"Details of injuries sustained","type":"text","label":"Describe the nature of injuries received.","options":[],"required":true,"pdf_field":""},{"help":"Duration of disability due to accident","type":"text","label":"Period of disability","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Total disability-confined to Bed","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Partial disability – confined to House","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"List duties not possible due to partial 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 inspection or 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"},{"title":"E. HOSPITALIZATION / TREATMENT DETAILS","fields":[{"help":"Doctor's name and contact info","type":"text","label":"Name & contact details of doctor first consulted after the accident","options":[],"required":true,"pdf_field":""},{"help":"Other doctors consulted if any","type":"text","label":"Name and contact details of other doctors consulted","options":[],"required":false,"pdf_field":""},{"help":"Regular doctor details","type":"text","label":"Name and contact details of claimant’s usual medical practitioner","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether hospitalized following the accident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Hospital details if admitted","type":"text","label":"If yes, name & address of hospital","options":[],"required":false,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"To","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"F. OTHER INSURANCES","fields":[{"help":"Provide insurer name, sum insured, policy number, period and coverage","type":"table","label":"Details of any other insurance (arranged by self, spouse, parents or employer) under which claimant/deceased is covered","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"G. CLAIM AMOUNT","fields":[{"help":"Date of claim form signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign to declare truthfulness","type":"signature","label":"Signature of Insured/claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Attendant’s Certificate","fields":[{"help":"Patient's full name","type":"text","label":"Name of patient","options":[],"required":true,"pdf_field":""},{"help":"Patient's occupation","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"Duration of doctor-patient relationship","type":"text","label":"How long have you known this patient?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the injury consistent with patient’s description of the accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you his/her usual Medical Attendant?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Describe injuries in detail","type":"text","label":"Kindly state the nature of and extent of injuries","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are the injuries connected with any previous accident, infirmity or disease?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of previous conditions","type":"text","label":"If yes, please provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Will the recovery be retarded due to above?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Explain factors delaying recovery","type":"text","label":"If yes, kindly provide details","options":[],"required":false,"pdf_field":""},{"help":"Date of first consultation","type":"date","label":"When were you first consulted for this injury/disability?","options":[],"required":true,"pdf_field":""},{"help":"Names of other doctors consulted","type":"text","label":"Please give details of other consultations – Doctor’s name","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you still treating the patient for the injury/disability","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Treatment details","type":"text","label":"Kindly provide details of treatment prescribed","options":[],"required":true,"pdf_field":""},{"help":"X-ray results and report","type":"text","label":"If X-ray has been done, kindly state the findings and Radiologist’s report","options":[],"required":false,"pdf_field":""},{"help":"Hospital name if admitted","type":"text","label":"If hospitalized, name of hospital","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are there any complications which may retard the recovery","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the patient suffered from similar injury/disability previously?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of previous similar injury treatment","type":"text","label":"If yes, when, nature and duration of the treatment","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the patient under the influence of intoxicants or drugs at the time of accident?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Duration of total disability","type":"text","label":"While under your care and direction, how long was or will the patient be: a) Totally unable to perform each and every duty of his/her usual occupation","options":[],"required":true,"pdf_field":""},{"help":"Duration of partial disability","type":"text","label":"b) Partially disabled from performing his/her usual occupation","options":[],"required":true,"pdf_field":""},{"help":"Doctor's prognosis","type":"text","label":"Prognosis: Please comment on any additional factor that may prolong recovery from injury/disability","options":[],"required":false,"pdf_field":""},{"help":"Surgery details if applicable","type":"text","label":"Date & Nature of surgical procedure, if any","options":[],"required":false,"pdf_field":""},{"help":"Description of permanent disability","type":"text","label":"Nature of disablement (in case of permanent disability)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Permanent Total Disability","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Permanent Partial disability","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Doctor's signature with official seal/stamp","type":"signature","label":"Signature*","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Reg. No.","options":[],"required":true,"pdf_field":""},{"help":"Date of certificate signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"Janata Personal Accident policy claims","attachments":["Post-mortem Report (if post-mortem conducted)","Medical Attendant’s Certificate","Other relevant medical reports and bills"],"declarations":["I warrant the truth of foregoing statement and declare no material information is suppressed or concealed.","I understand false declarations may result in claim refusal by Magma General Insurance Limited.","I authorize any hospital, physician or medical provider to furnish Magma General Insurance Limited details of my medical history/treatment."],"dropped_labels":1},"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/746-claim-form-janata-personal-accident"}