{"id":819,"title":"SHOPKEEPER’S PACKAGE POLICY (RETAIL) Personal Accident Insurance 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+%E2%80%93+Shopkeeper%27s+Package+%281%29.pdf/e49652d6-f583-a210-b188-52d50421b923?t=1789044311757","sha256":"d41e2d593bbf17f0d57a762fe3b9a283fad432c5401876ab4db404ccb0c060b6","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to file a personal accident insurance claim under the Shopkeeper's Package Policy (Retail).","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.","The issue or acceptance of this form is not an admission of liability by Magma General Insurance.","Kindly affix official seal/stamp on Medical Attendant’s Certificate.","Documents to be attached as listed must be submitted with the claim form."],"title":"SHOPKEEPER’S PACKAGE POLICY (RETAIL) Personal Accident Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. The Insured","fields":[{"help":"","type":"text","label":"Name :","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address :","options":[],"required":true,"pdf_field":""},{"help":"Office telephone number","type":"phone","label":"Tel No. : Office :","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile :","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"B. Policy Details","fields":[{"help":"Policy number as per insurance documents","type":"text","label":"Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"Start date of policy coverage","type":"date","label":"Period of Insurance :","options":[],"required":true,"pdf_field":""},{"help":"End date of policy coverage","type":"date","label":"to","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"C. Claimant","fields":[{"help":"Name of the claimant","type":"text","label":"(a)  Name  :","options":[],"required":true,"pdf_field":""},{"help":"Claimant's full postal address","type":"text","label":"Address :","options":[],"required":true,"pdf_field":""},{"help":"Claimant's office phone number","type":"phone","label":"Tel No. :. Office :","options":[],"required":false,"pdf_field":""},{"help":"Claimant's mobile number","type":"phone","label":"Mobile  :","options":[],"required":false,"pdf_field":""},{"help":"Claimant's email address","type":"email","label":"Email :","options":[],"required":false,"pdf_field":""},{"help":"Relationship to the insured person","type":"text","label":"Relationship with insured person :","options":[],"required":true,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"(b) Insured person’s details Name :","options":[],"required":true,"pdf_field":""},{"help":"Select gender of insured person","type":"choice","label":"Sex : Male    Female ","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Date of birth of insured person","type":"date","label":"Date of Birth :","options":[],"required":true,"pdf_field":""},{"help":"Occupation of insured person","type":"text","label":"Occupation :","options":[],"required":true,"pdf_field":""},{"help":"ID number if applicable for group policies","type":"text","label":"Employee/Member identification number (for group policies) :","options":[],"required":false,"pdf_field":""},{"help":"Address for medical visit","type":"text","label":"Address where a Medical Practitioner on behalf of Magma General Insurance I  can  visit :","options":[],"required":false,"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/pm","type":"text","label":"Time of accident :","options":[],"required":true,"pdf_field":""},{"help":"Indicate if accident happened at work","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":"Indicate if police was informed","type":"yes-no","label":"Was the accident reported to Police : Yes    No  ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Police station name, FIR number and date if FIR lodged","type":"text","label":"If Yes—Name of the police station where FIR was lodged and FIR No and date :","options":[],"required":false,"pdf_field":""},{"help":"Reason for not reporting to police","type":"text","label":"If not, kindly state the reasons :","options":[],"required":false,"pdf_field":""},{"help":"Indicate if witnesses exist","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":"Details of injuries sustained","type":"text","label":"Describe the nature of injuries received :","options":[],"required":true,"pdf_field":""},{"help":"Start and end dates of total disability","type":"date","label":"Period of disability :- Total disability- confined to Bed : (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Start and end dates of partial disability","type":"date","label":"Partial disability – confined to House : (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"List duties not performable 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":"Date and time of death if applicable","type":"text","label":"In case of death of insured person, kindly provide following information : Date and time of death :","options":[],"required":false,"pdf_field":""},{"help":"Indicate if post-mortem was done","type":"yes-no","label":"Whether post-mortem was conducted : Yes    No  ","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Reason if post-mortem not conducted","type":"text","label":"If not, please give reason :","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"E. Hospitalisation / 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","type":"text","label":"Name and contact details of other doctor consulted :","options":[],"required":false,"pdf_field":""},{"help":"Usual medical practitioner's details","type":"text","label":"Name and contact details of claimant’s usual medical practitioner :","options":[],"required":false,"pdf_field":""},{"help":"Indicate if hospitalized","type":"yes-no","label":"Whether hospitalized following the accident : Yes    No  ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Hospital name and address","type":"text","label":"If yes, name & address of hospital :","options":[],"required":false,"pdf_field":""},{"help":"Hospitalization start and end dates","type":"date","label":"Period of hospitalization : (dd/mm/yy) to","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"F. Other Insurances","fields":[{"help":"Name of other insurer","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":"Sum insured under other insurance","type":"amount","label":"Coverage Capital Sum insured","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"G. Claim Amount and Declaration","fields":[{"help":"Sign to declare truthfulness and authorize medical info release","type":"signature","label":"Signature of Insured/claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"To be completed by Employer (for group policies)","fields":[{"help":"Employee details and leave period","type":"text","label":"Mr./Ms____________________, working as ________________, permanent Employee Id No._______ covered under Group Personal Accident Policy No.________________ was on leave for the period _____/_____/______ to ______/______/______.","options":[],"required":true,"pdf_field":""},{"help":"Capital sum insured amount","type":"amount","label":"Mr/Ms. is covered under the policy for a capital sum insured of Rs.______.","options":[],"required":true,"pdf_field":""},{"help":"Number of permanent employees","type":"number","label":"The total number of employees on permanent rolls as on the date of accident was______.","options":[],"required":true,"pdf_field":""},{"help":"Employer's authorized signature","type":"signature","label":"Signature of Authorised signatory","options":[],"required":true,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name and designation of signatory","type":"text","label":"Name & Designation of Authorized signatory","options":[],"required":true,"pdf_field":""},{"help":"Company seal or stamp","type":"attachment","label":"Company Seal","options":[],"required":true,"pdf_field":""}],"filled_by":"employer"},{"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 doctor has known patient","type":"text","label":"How long have you known this patient","options":[],"required":false,"pdf_field":""},{"help":"Indicate if usual medical attendant","type":"yes-no","label":"Are you his/her usual Medical Attendant :  Yes      No  ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe injuries and extent","type":"text","label":"Kindly state the nature of and extent of injuries :","options":[],"required":true,"pdf_field":""},{"help":"Confirm if injury matches claimant's account","type":"yes-no","label":"Is the injury consistent with  claimant’s description of the accident :     Yes      No  ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if injuries relate to prior 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 any","type":"text","label":"If yes, please provide details;","options":[],"required":false,"pdf_field":""},{"help":"Indicate if recovery will be delayed","type":"yes-no","label":"Will the recovery be retarded due to above  : Yes      No  ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details on delayed 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 (dd/mm/yy) :","options":[],"required":true,"pdf_field":""},{"help":"Other doctors consulted","type":"text","label":"Please give details of other consultations – Dr’s name, address :","options":[],"required":false,"pdf_field":""},{"help":"Indicate if treatment ongoing","type":"yes-no","label":"Are you still treating the patient for the injury/disability :  Yes     No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of treatment given","type":"text","label":"Kindly provide details of treatment prescribed  :","options":[],"required":false,"pdf_field":""},{"help":"X-ray findings 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":"Hospitalization dates","type":"date","label":"Period of hospitalization :  (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Surgery date and details","type":"text","label":"Date & Nature of surgical procedure, if any  (dd/mm/yy) :","options":[],"required":false,"pdf_field":""},{"help":"Complications affecting recovery","type":"text","label":"Are there any complications which may retard the recovery :","options":[],"required":false,"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","type":"text","label":"If yes, when, nature and duration of the;","options":[],"required":false,"pdf_field":""},{"help":"Indicate if patient was intoxicated","type":"yes-no","label":"Was the patient under the influence of intoxicants or drugs at the time of accident : Yes     No ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Total disability period","type":"date","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 From (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Partial disability period","type":"date","label":"b) Partially disabled from performing his/her usual occupation (dd/mm/yy) to","options":[],"required":false,"pdf_field":""},{"help":"Description of permanent total disability","type":"text","label":"Nature of disablement (in case of permanent disability) Permanent Total disability :","options":[],"required":false,"pdf_field":""},{"help":"Details and percentage of permanent partial disability","type":"text","label":"Permanent partial disability, If yes, give details and percentage of disability :","options":[],"required":false,"pdf_field":""},{"help":"Cause of death if applicable","type":"text","label":"In case of death of insured person, kindly state the cause of death :","options":[],"required":false,"pdf_field":""},{"help":"Doctor's prognosis","type":"text","label":"Prognosis :","options":[],"required":false,"pdf_field":""},{"help":"Additional factors affecting recovery","type":"text","label":"Please comment on any additional factor that may prolong recovery from injury/disability:","options":[],"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":"Doctor's registration number","type":"text","label":"Reg.No. :","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name :","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address :","options":[],"required":true,"pdf_field":""},{"help":"Date of certificate","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"Personal Accident Insurance claims under Shopkeeper's Package Policy (Retail)","attachments":["Police Report/Panchnama","Post Mortem Report","Death Certificate","Copies of record of treatment including X rays, investigation reports","Cash memos, Bills and receipts in case medical expenses are covered","Any other document as may be required"],"declarations":["The claimant warrants the truth of the statements and declares no material information is suppressed or concealed.","False declarations may result in refusal of claim payment by Magma General Insurance.","The claimant authorizes hospitals, physicians or medical providers to furnish medical details to Magma General Insurance."],"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/819-shopkeepers-package-policy-retail-personal-accident-insurance-claim-form"}