{"id":749,"title":"GROUP ACCIDENT SURAKSHA POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Claim+Form+-+Group+Accident+Suraksha.pdf/83e05600-4bdb-5c37-553a-6143c9487d43?t=1765014160063","sha256":"aad5e26b27b1bad4e066754d0d788fb179c5362a15e0ed875034a926e6abe275","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used to claim benefits under the Group Accident Suraksha insurance policy. It is filled by the insured or claimant and the attending physician.","notes":["Issue of this claim form is not to be taken as an admission of liability","If any detail or information is not readily available please do not delay the dispatch of this form and other particulars may be sent later","Please attach separate sheet in the medical expenses section for additional bills"],"title":"GROUP ACCIDENT SURAKSHA POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the Insured/Claimant","fields":[{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"From and To dates","type":"date","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Specify relation to the insured person","type":"text","label":"Relation with the insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal PIN code","type":"number","label":"Pin No","options":[],"required":null,"pdf_field":""},{"help":"Phone number with country/area code if applicable","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Accident Details","fields":[{"help":"Date and time when accident happened","type":"date","label":"Date & time of Accident/occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location where accident occurred","type":"text","label":"Place of Accident/Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Brief description of how the accident happened","type":"text","label":"Description of the Accident/Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Details of any witnesses","type":"text","label":"Witness name, address and contact number","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Was the injured person under the influence of alcohol/drugs at the time of accident","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide driving license details if applicable","type":"text","label":"Driving license details, in case of self-accident","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Injury/Death","fields":[{"help":"Describe injuries and affected body parts","type":"text","label":"Details of injuries sustained with name of the parts","options":[],"required":null,"pdf_field":""},{"help":"Describe disability if any","type":"text","label":"If disabled, specify the nature of disability","options":[],"required":null,"pdf_field":""},{"help":"Enter disability percentage","type":"number","label":"Specify the disability percentage in case of Permanent Partial Disablement","options":[],"required":null,"pdf_field":""},{"help":"Cause of death if applicable","type":"text","label":"In case of death, Cause of death","options":[],"required":null,"pdf_field":""},{"help":"Nominee details for death claims","type":"text","label":"Nominee details (for death cases only) Name, relation with the insured and address","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Treatment Details","fields":[{"help":"","type":"text","label":"Casualty Doctor Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Family Doctor Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital Details Name","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Confinement Details","fields":[{"help":"Start date of partial confinement","type":"date","label":"Partial Confinement Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claims History","fields":[{"help":"Select yes or no","type":"yes-no","label":"Have you made any claims in the past?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if previous claims were made","type":"text","label":"If Yes, Please give the details of cause of accident/occurrence, nature of injury, policy details and claim amount","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Other Insurance","fields":[{"help":"Select yes or no","type":"yes-no","label":"Are you insured under any other policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"If Yes, Please give full particulars of Name of the insurance company, Policy number, period of insurance and claim details","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claim Under Other Heading","fields":[{"help":"Specify coverage under which claim is made","type":"text","label":"Claim Under Which Coverage","options":[],"required":false,"pdf_field":""},{"help":"Amount claimed under other coverage","type":"amount","label":"Claimed Amount","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of claimant or nominee","type":"signature","label":"Signature of the insured /Nominee","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/nominee"},{"title":"Attending Physician’s Statement","fields":[{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age of the insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nature of injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Does the Cause of accident as stated by the Claimant tally with the Injuries noticed by you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Was the injured person suffering from any disease or injury which may have contributed to the accident or likely to aggravate his condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospitalisation start date","type":"date","label":"Was the Claimant hospitalised, if yes period From","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Was the treatment /Operations carried by you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital treatment start date","type":"date","label":"Give details of the treatment Hospital From","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Was he/she was under the influence of intoxicants or drugs at the time of accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details if under influence","type":"text","label":"If Yes, please provide the details","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Are you his/her family doctor","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of previous treatment if family doctor","type":"text","label":"If yes, have you treated him/her for any previous illness or injury, please provide the details","options":[],"required":false,"pdf_field":""},{"help":"Details of other doctors involved","type":"text","label":"Is there any Doctors also associated in the treatment, please provide the details","options":[],"required":false,"pdf_field":""},{"help":"Police report details if applicable","type":"text","label":"Has the accident been reported to the Police Authorities, if yes please provide the details","options":[],"required":false,"pdf_field":""},{"help":"State if claimant is totally disabled","type":"text","label":"Is the claimant Totally Disable from each and every occupation","options":[],"required":false,"pdf_field":""},{"help":"Start date of total disability","type":"date","label":"How long the claimant will be totally disabled from current occupation From","options":[],"required":false,"pdf_field":""},{"help":"End date of total disability","type":"date","label":"How long the claimant will be totally disabled from current occupation To","options":[],"required":false,"pdf_field":""},{"help":"Start date of partial disability","type":"date","label":"How long the claimant will be partially Disabled from the current location From","options":[],"required":false,"pdf_field":""},{"help":"End date of partial disability","type":"date","label":"How long the claimant will be partially Disabled from the current location To","options":[],"required":false,"pdf_field":""},{"help":"Expected date claimant can resume work","type":"date","label":"Estimated date of return to work","options":[],"required":false,"pdf_field":""},{"help":"Doctor's prognosis","type":"text","label":"What is the Prognosis","options":[],"required":false,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"attending physician"}],"deadlines":[],"applies_to":"Group Accident Suraksha Policy claims","attachments":["Claim Form","Police FIR / Panchnama","Medical Certificate","Investigation/Lab Test Report","Discharge Certificate","Leave Certificate","Disability Certificate","Death Certificate – for Death cases only","Post Mortem Report – for Death cases only"],"declarations":["I/We agree to provide additional information to the company if required","I/We warrant the truth of the statements made in this form to the best of my/our knowledge and belief","If any false or fraudulent statement or concealment is made, the policy shall be void and rights to recover under it forfeited"],"dropped_labels":16},"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/749-group-accident-suraksha-policy-claim-form"}