{"id":805,"title":"Employee’s Compensation Insurance Claim Form","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/5571045/Claim+Form+%E2%80%93+Householder%27s+Package+%288%29.pdf/95e4c5f8-b72b-26f5-1379-6c9aa37129a7?t=1789043019455","sha256":"cefbfbd98c145bc5f7458c4081b8f4adab30bed7a06a3d4c6ecc696f7c389bd4","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured employer to claim employee’s compensation insurance benefits for an injured employee under the Householder’s Package Policy. The employer or authorized signatory fills it.","notes":["All questions must be answered fully; use a separate sheet if space is insufficient.","The issue or acceptance of this form is not an admission of liability by Magma General Insurance.","Provide accurate details of wages for the last 12 months or shorter period as applicable.","Attach relevant documents as per the list provided.","Signature and company seal required where indicated."],"title":"Employee’s Compensation Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. The Insured","fields":[{"help":"Enter the full name of the insured employer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the full postal address of the insured employer","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter office telephone number","type":"phone","label":"Tel No. Office","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":"Name of contact person for claim","type":"text","label":"Contact name","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of contact person","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email of contact person","type":"email","label":"email","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"B. Policy Details","fields":[{"help":"Enter the policy number","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter start and end dates of insurance period","type":"date","label":"Period of Insurance","options":[],"required":true,"pdf_field":""}],"filled_by":"insured employer"},{"title":"C. Injured Person Details","fields":[{"help":"Full name of injured employee","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Age of injured employee","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Local address of injured employee","type":"text","label":"Local Address","options":[],"required":true,"pdf_field":""},{"help":"Native place address of injured employee","type":"text","label":"Native place address","options":[],"required":false,"pdf_field":""},{"help":"Father’s name of injured employee","type":"text","label":"Father’s name","options":[],"required":false,"pdf_field":""},{"help":"Job title or occupation of injured employee","type":"text","label":"Occupation for which injured was employed","options":[],"required":true,"pdf_field":""},{"help":"Describe the work being done at time of accident","type":"text","label":"Nature/description of job being performed by injured person at the time of accident","options":[],"required":true,"pdf_field":""},{"help":"Select if injured was directly employed by you","type":"choice","label":"Is the injured person directly under your employment","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If not directly employed, specify employer and role","type":"text","label":"If not, for whom and in what capacity the injured was working at the time of accident","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"D. Details of Accident","fields":[{"help":"Date when accident occurred","type":"date","label":"Date of accident","options":[],"required":true,"pdf_field":""},{"help":"Time of accident with am/pm","type":"text","label":"Time of accident","options":[],"required":true,"pdf_field":""},{"help":"Exact location of accident","type":"text","label":"Place of accident (exact premises/address)","options":[],"required":true,"pdf_field":""},{"help":"Date/time and source of accident report","type":"text","label":"When did you receive intimation of accident and from whom","options":[],"required":true,"pdf_field":""},{"help":"Describe how accident happened","type":"text","label":"How did the accident occur","options":[],"required":true,"pdf_field":""},{"help":"Select if accident was work-related","type":"choice","label":"Are you satisfied that the accident occurred in the course of and arising out of employment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select if injured was intoxicated","type":"choice","label":"Was the injured person under the influence of drugs or drinks at the time of accident ?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select if injured disobeyed rules","type":"choice","label":"Was the injured person guilty of misconduct or disobedience of orders/rules","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain misconduct if applicable","type":"text","label":"If yes, provide details","options":[],"required":false,"pdf_field":""},{"help":"List names of accident witnesses","type":"text","label":"Names of witnesses","options":[],"required":false,"pdf_field":""},{"help":"Select if accident was reported to authorities","type":"choice","label":"Is the accident reported to Police or any other authority","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach police or authority report if available","type":"attachment","label":"If yes, attach a copy of the report.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"E. Details of Injury & Treatment","fields":[{"help":"Describe the injury sustained","type":"text","label":"Nature of injury","options":[],"required":true,"pdf_field":""},{"help":"Specify body parts injured","type":"text","label":"Parts/Regions of body affected","options":[],"required":true,"pdf_field":""},{"help":"Specify left or right side if applicable","type":"text","label":"Whether left side or right side","options":[],"required":false,"pdf_field":""},{"help":"Hospital where treatment was given","type":"text","label":"Name & Address of hospital treated at","options":[],"required":true,"pdf_field":""},{"help":"State current hospitalization status","type":"text","label":"Whether still in hospital or discharged","options":[],"required":true,"pdf_field":""},{"help":"Medical assessment of disability","type":"text","label":"What is the medical opinion on nature and extent of disablement","options":[],"required":true,"pdf_field":""},{"help":"Select if injured has resumed work","type":"choice","label":"Whether returned to work","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Expected date to return to work","type":"date","label":"If not, likely date of resumption of duty","options":[],"required":false,"pdf_field":""},{"help":"Estimated duration of disability","type":"text","label":"What is the probable period of disablement","options":[],"required":true,"pdf_field":""}],"filled_by":"insured employer"},{"title":"Declaration and Signature","fields":[{"help":"Sign to declare correctness of information","type":"signature","label":"Signature of authorized signatory","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Affix company seal if applicable","type":"text","label":"Company seal","options":[],"required":false,"pdf_field":""}],"filled_by":"authorized signatory of insured employer"},{"title":"Statement of Wages","fields":[{"help":"Sign to confirm accuracy of wages statement","type":"signature","label":"Signature of employer/authorized signatory","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Affix company seal if applicable","type":"text","label":"Company Seal","options":[],"required":false,"pdf_field":""}],"filled_by":"employer or authorized signatory"}],"deadlines":[],"applies_to":"Employee’s Compensation Insurance under Householder’s Package Policy (Retail)","attachments":["FIR","Medical certificate/treatment documents","Fitness Certificate","Death certificate","Post Mortem Certificate","Age proof","Statement of witness","Summons from WC Commissioner","Report to Inspector of Labour","Petition"],"declarations":["I/We declare that I/We have not withheld any material information and that all statements made on this form are true to the best of my/our knowledge and belief.","I/We understand that the claim may be refused if the information is untrue, inaccurate or concealed."],"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/805-employees-compensation-insurance-claim-form"}