Accident Claim Form

Insured Details

Policy Number / Id Card Policy Number / Id Card

Patient's Full Name Please enter a patient's full name

Insured's Mobile Number Please enter a mobile number

Insured's Email id Please enter a Email ID

Claim Details

Type of claim

Death PTD PPD TTD

Please select a option

Claimed Amount Please enter claimed amount

Date of Loss and Time

Please select date of loss

Brief Description of Accident Along With the Place of Accident Please enter Description of Accident Along With the Place of Accident

Hospital Details

Hospital Name Please enter hospital name

Hospital Address Please Enter Hospital address

Name of the Person Who Took Insured to the Hospital Please Enter Name of the Person Who Took Insured to the Hospital

Name & Address of Police Station if FIR Filed Please enter Name & Address of Police Station If FIR Filed

Claim

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