{"id":925,"title":"CLAIM FORM","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeswari%20Freedom_Claim%20Form.pdf","sha256":"74f36a6026dde65fa13c46e94704055236aefd4bcb2f774b677f3e77ac8ffa9f","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the National Rajrajeshwari Women's Freedom Policy. It is to be completed by the insured or on their behalf if they are unable to do so.","notes":["The claim form is to be completed by the insured or on their behalf if unable","Each and every question must be answered fully","Fill the form in block letters","Attach original or attested documents as listed","Use correct date and time formats as indicated"],"title":"CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"Fill in the full name of the insured person","type":"text","label":"a) Name of the Insured :","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"b) Age:","options":[],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"c) Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Specify the insured's occupation","type":"text","label":"f) Profession or Occupation of the Insured:","options":[],"required":true,"pdf_field":""},{"help":"Enter the policy number exactly as on the policy document","type":"text","label":"g) Policy number:","options":[],"required":true,"pdf_field":""},{"help":"Enter start and end dates of the policy period","type":"date","label":"h) Policy Period: From / To","options":[],"required":true,"pdf_field":""},{"help":"Provide a phone number to contact","type":"phone","label":"e) Contact number:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Claim Type Selection","fields":[{"help":"Select the type of claim being made","type":"choice","label":"PLEASE SELECT APPROPRIATE OPTION FOR COMPENSATION","options":["Permanent Total Disablement","Loss of 2 limbs or 2 eyes or 1 limb & 1 eye","Loss of 1 limb or 1 eye","Death of unmarried women","Death of married Insured","Death of husband of married women","Critical Illness","Daily Cash Allowance","Funeral Expenses","Temporary Total Disablement","Legal Divorce","Children's Education Benefit","Loss or damage to household goods/personal effects"],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Details of Injured Person","fields":[{"help":"Date when the accident occurred","type":"date","label":"a) Date of Accident:","options":[],"required":true,"pdf_field":""},{"help":"Enter time in HH:MM format with AM/PM","type":"text","label":"b) Time of Accident:","options":[],"required":true,"pdf_field":""},{"help":"Location of the accident","type":"text","label":"c) Where it happened ?","options":[],"required":true,"pdf_field":""},{"help":"Describe the circumstances of the accident","type":"text","label":"d) State how did Accident occur ?","options":[],"required":true,"pdf_field":""},{"help":"Indicate if the accident was reported to police","type":"yes-no","label":"e) Whether reported to police?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide police station details if reported","type":"text","label":"f) If yes, Name and Address of Police Station","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any eyewitness","type":"text","label":"g) Name and Address of eye witness, if any?","options":[],"required":false,"pdf_field":""},{"help":"Describe injuries in detail","type":"text","label":"h) State as fully as you can, the nature and extent of the injuries substained ?","options":[],"required":true,"pdf_field":""},{"help":"Answer about insured's health condition before accident","type":"yes-no","label":"i) Was the Insured Person in good Health and free from physical defect at the time of the accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide treatment facility details","type":"text","label":"j) Give the Name and Address of the Hospital/Doctor/Nursing Home where the insured person for these injuries is being treated?","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Details for Children's Education Benefit","fields":[{"help":"Enter name of first child","type":"text","label":"a) Name of Child 1:","options":[],"required":false,"pdf_field":""},{"help":"Age in years","type":"number","label":"c) Age:","options":[],"required":false,"pdf_field":""},{"help":"Enter name of second child","type":"text","label":"a) Name of Child 2:","options":[],"required":false,"pdf_field":""},{"help":"Age in years","type":"number","label":"c) Age:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Details for Death of Husband Claim","fields":[{"help":"Enter husband's full name","type":"text","label":"a) Name of husband:","options":[],"required":false,"pdf_field":""},{"help":"Age in years","type":"number","label":"c) Age:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Nominee Details (in case of Insured's death)","fields":[{"help":"Enter full name of nominee","type":"text","label":"a) Name of the Nominee:","options":[],"required":true,"pdf_field":""},{"help":"Select nominee's gender","type":"choice","label":"b) Gender:","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"c) Age:","options":[],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"d) Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"e) Address:","options":[],"required":true,"pdf_field":""},{"help":"City name","type":"text","label":"City:","options":[],"required":true,"pdf_field":""},{"help":"State name","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin Code:","options":[],"required":true,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"nominee"},{"title":"Details of Loss or Damage","fields":[{"help":"Date when loss occurred","type":"date","label":"a) Date of loss:","options":[],"required":false,"pdf_field":""},{"help":"Time in HH:MM format with AM/PM","type":"text","label":"b) Time of loss:","options":[],"required":false,"pdf_field":""},{"help":"Location of loss","type":"text","label":"c) Where it happened ?","options":[],"required":false,"pdf_field":""},{"help":"Describe how the loss happened","type":"text","label":"d) State how did loss occur ?","options":[],"required":false,"pdf_field":""},{"help":"Explain cause and nature of loss","type":"text","label":"e) Cause and Nature of loss","options":[],"required":false,"pdf_field":""},{"help":"List damaged goods with quantity and amount","type":"table","label":"f) Particulars of damaged articles","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Other Insurance Details","fields":[{"help":"Provide details of other insurance if applicable","type":"text","label":"l) Is the claim being made under any other Personal Accident Insurance? If so, please state the name and address of the insurance Company alongwith its Policy Number?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Declaration","fields":[{"help":"Sign to declare the information is true and authorize medical information access","type":"signature","label":"Declaration by Insured/Nominee","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 or nominee"}],"deadlines":["Post mortem report if necessary, be furnished within the space of fourteen days after demand in writing"],"applies_to":"National Rajrajeshwari Women's Freedom Policy claims including accident, death, disablement, critical illness, daily cash allowance, funeral expenses, legal divorce, children's education benefit, and loss or damage to household goods/personal effects","attachments":["Attending Doctors Report","Original policy for cancellation","Disability Certificate from Govt. Registered Medical Practitioners, where applicable","Original / attested Post Mortem / Coroners Report","Attested copy of FIR / Panchnama","Post mortem report if necessary, be furnished within the space of fourteen days after demand in writing","Police Inquest report, where applicable","Original Death Certificate","Diagnostic reports like laboratory test, X-rays and/or any other reports confirming injury","Certificate of proof of age","Divorce decree","Any other document required by the company"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief","False or untrue statements, suppression or concealment of material facts will forfeit the right to compensation","Consent and authorization to the insurance company to seek necessary medical information/documents from any hospital or medical practitioner"],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/national-insurance/925-claim-form"}