{"id":787,"title":"Clinical Trial Liability (Commercial) Claims Form","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Clinical+Trials+Liability+Claims+form.pdf/7c663f4b-64d1-12f0-d2d5-0b6d3f930e94?t=1789044322518","sha256":"ad2f2dcdbbb4d0090ef88405a41473ff0e488c1b64a610a57a7a0e80dac082e5","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Clinical Trial Liability insurance policy and is to be completed and signed by a Director, Partner, or Principal of the Insured.","notes":["The form must be completed and signed by a Director, Partner or Principal of the Insured.","Appointment of legal representatives should not occur without prior consent of Magma General Insurance Ltd.","If any detail or information is not readily available, do not delay dispatch of this form; such particulars may be sent later."],"title":"Clinical Trial Liability (Commercial) Claims Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full name of insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registered address of insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal PIN code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include area code if applicable","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"Details of Claimant","fields":[{"help":"","type":"text","label":"Full name of Claimant or potential claimant (i.e. party claiming against you)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Complete address of claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal PIN code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include area code if applicable","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"Details of Insured’s Contract with Claimant","fields":[{"help":"Describe the services provided under the contract","type":"text","label":"What were you retained or contracted to do (details of services)","options":[],"required":null,"pdf_field":""},{"help":"Attach contract copy if available","type":"text","label":"Were your retainership / contract evidenced in writing? If so, please attach a copy, otherwise, please provide appropriate particulars","options":[],"required":null,"pdf_field":""},{"help":"Describe the specific work related to the claim","type":"text","label":"What work/services are performed on which the claim arises or may arise","options":[],"required":null,"pdf_field":""},{"help":"Provide the date(s) of the work performed","type":"date","label":"When did you perform the work on which the claim arises or may arise","options":[],"required":null,"pdf_field":""},{"help":"Provide full name, designation and work profile","type":"text","label":"Name, designation work profile of the person within your company who performed the work or against whom the claim or potential claim is directed","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"Details of Claim","fields":[{"help":"Describe the claim or circumstances in detail","type":"text","label":"What is the precise nature of the claim (i.e. the claimant’s allegations on the insured) or the circumstances which might give rise to a potential claim","options":[],"required":null,"pdf_field":""},{"help":"Provide date and attach correspondence if any","type":"date","label":"On which date did you first become aware of the claim or the circumstances leading to a claim. If received by you in writing, please provide a copy of the correspondence. If oral, please give a first person account of the conversation","options":[],"required":null,"pdf_field":""},{"help":"Provide claim amount and breakdown if possible","type":"amount","label":"What amount is being claimed Please provide breakup, if available","options":[],"required":null,"pdf_field":""},{"help":"Provide your response and opinion on claim amount","type":"text","label":"What are your comments in response to the claim and your opinion on the quantum of claim","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional relevant information and attach documents","type":"text","label":"Are there any other details that you might wish to share with MagmaGI or which could be of interest so that We might have a better understanding of the circumstances leading to the claim. Please provide documents, if any.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of legal representative if engaged","type":"text","label":"As of now, have you engaged any legal representative to act for you. If so, please provide name, firm, address and charge out rates","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"Declaration and Authorization","fields":[{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Print full name of the signatory","type":"text","label":"Full Name of Person Signing","options":[],"required":true,"pdf_field":""},{"help":"Provide designation of the signatory","type":"text","label":"Designation of the Person Signing","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured"}],"deadlines":[],"applies_to":"Clinical Trial Liability (Commercial) insurance claims","attachments":["Copy of retainership / contract if evidenced in writing","Correspondence related to the claim if received in writing","Any other documents relevant to the claim"],"declarations":["The information and answers given above are true, correct and complete in every detail.","The claim may be refused if information is not true or is withheld.","Authorization for Magma General Insurance Ltd. to exchange information with other insurers, government bureaus or any other agency for decision on indemnity."],"dropped_labels":0},"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/787-clinical-trial-liability-commercial-claims-form"}