Accidental Insurance Claim Form

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ANNEX - A

Claims Process-RuPay Card for Personal Accident Benefit Policy No - 2999200723397400000 Claim intimation All the claims will intimate to the dedicated claims id [email protected] and HDFC ERGO will register the claim and provide the claim number to the Member Bank within 2 working days with policy number in subject line. Documents receipt / Follow-up All documents are to be received at HDFC ERGO office at the below mentioned address as per zones: Zone West: Card claims Claims Manager HDFC ERGO General Insurance Company Limited 6th Floor, Leela Business Park Andheri-Kurla Road, Andheri (E), Mumbai- 400 079 Phone no: 022 -66383600 Zone North Card Claims, Claims Manager, HDFC ERGO General Insurance Company Limited 5th floor, Tower 1, Stellar IT Park, C-25, Sector-62, Noida201301 Phone no: 1206691600 Zone East Card Claims, Claims

Manager, HDFC ERGO General Insurance Company Limited Metro Towers, 10th Floor, 1 Ho Chi Minh Sarani, Kolkata: 700071 Phone no: 033-39883600 Zone South Card Claims, Claims Manager, HDFC ERGO General Insurance Company Limited 6th floor, MBC Tower, Old No.90, New No.199, Luz Church Road, Mylapore, Chennai 600 004 Phone no : 04439883600 •

Claim intimation should be within Thirty (30) days from the date of Loss. In case where a person is hospitalized (and under a critical condition) and is unable to file claim within 30 days of loss/incident such claim cases will be honored by HDFC Ergo if all terms under the policy are met as on date of loss. Here “date of loss” is the date on which incident has occurred.



All supporting documents relating to the claim must be submitted within sixty (60) days from the date of loss.



The claims will be settled in 10 working days from the date of receiving the complete documents set.



In case documents are not received within 60 days of claim intimation, 1 reminder hard copy letter will be issued to Member Bank, followed by an email communication.



2 reminder hard copy letter will be sent after 81 days from claim intimation followed by an email.



Closure letter hard copy letter will be sent to Member Bank on 90 day from claim intimation in case of no communication received from Member Bank.

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Investigator appointment Based on the merit of the claim HDFC ERGO’s investigation team shall be appointed. TAT: T +3 (T is the day on which the claim documents received from the Member Bank)

In 30 days, Investigation report will be finalized. If there is a delay because of the some more facts, an interim report will be requested.

Claims Follow up / Processing The reminders shall be sent to Member Bank in regular intervals for claim documents, a communication via letter in hard copy / email will be sent to client with defined timeline. Reminder process would be same for the documents deficiency also st 1 reminder T+61 nd 2 reminder T+81 Closure Letter T+90 T is Date of Intimation

Escalation Matrix For claims First level Contact [email protected] m

Second level Contact Mr. Parimal Machhi – Claims Manager Email: [email protected] Contact: 9820789099 Third level Contact Mr. Venkatrao Kulkarni AVP – Claims Email: [email protected] Contact: 9833097673, 022-66383600 extn:3229 Fourth level Contact Mr. Vikram Kumar SinghKashayap Dakshini Sr VP - Claims Email: [email protected] Contact: 08373915558 For Policy Administartion First Contact Amita Desai VP - CBG Email: [email protected] Contact : 9930266024

Second Contact Sanjay Kaw Executive VP- Corporate Business Group Email: [email protected] Contact: 09930266037

Claim Payment Once the claim is approved the payment in the form of NEFT shall be done to the card holder beneficiary along with a covering letter. Document check list – Accidental Death Claim: – 1) Duly filled and signed claim form 2) FIR copy 3) Post mortem report 4) “Cause of Death” certificate from treating doctor 5) Death Certificate – issued by a municipal authority 6) Viscera report (If done) 7) Passport, Pan Card, Aadhaar card, address proof (KYC documents) 8) Copy of the RuPay card / Declaration from Bank on letter head with sign and stamp 9) Switch Log / Core Banking System screenshot from Bank for Transaction verification 10) Declaration from Bank for nominee including NEFT details with sign and stamp (in case nominee is available) / legal heir certificate or any other document in discussion with claimant as a proof (in case nominee not available with bank)

Permanent Disability Claim: – 1) Duly filled and signed claim form 2) FIR copy 3) Disability certificate from treating doctor / Government hospital 4) Hospital Indoor case paper 5) Full size photo of insured with disable / Amputed limb 6) Passport, Pan Card, Aadhaar card, address proof (KYC documents) 8) Copy of the RuPay card / Declaration from Bank on letter head with sign and stamp 9) Switch Log / Core Banking System screenshot from Bank for Transaction Verification

Accidental Death

Form ‘E’

Claimant’s Statement INSURED INFORMATION Insured’s Name________________________________ Date of Birth ___/____/____ Marital Status _____ Insured’s Address ____________________________________________________________________________ Name and address of Last Employer _______________________________________________________________________________________ Policy Number __________________________ Insured’s Occupation (at time of death) __________________ Did the Insured have any other accident or life insurance? _________ If yes, please list all companies, policy numbers and insurance amounts:__ ________________________________________________________________________ CLAIM INFORMATION Date of accident ______/_______/______ Time and place accident occurred________________________________________ Please describe in detail the circumstances of accident (attach separate sheet if needed): ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Was the accident related to the Insured’s occupation? ___________________ If so, how? ___________________________ Please describe the cause of the Insured’s death: ____________________________________________________________________________ Please list the names and addresses of all treating physicians and hospitals:________________________________________ ________________________________________________________________________________________________________ Did police or other authorities investigate the accident? ____ If yes, please provide name, address and telephone number of all investigating officers and agencies: _____________________________________________________________________

Was an autopsy performed?______ If yes, please provide name and address of Medical Examiner____________________ ________________________________________________________________________________________________________

Was a coroner’s inquest held? _______If yes, what was the determination?_______________________________________ CLAIMANT INFORMATION Claimant’s Name___________________________________________ Age_______ Relationship to Insured______________ Claimant’s Address____________________________________________ Phone No. (H)____________________________ ____________________________________________________________ Phone No. (W)____________________________ In what capacity are you making this claim? _____ Beneficiary ______ Executor* ______ Administrator* _____ Guardian* _____Trustee* _____Assignee* *Please provide a certified copy of all documents supporting your authority (e.g., Succession Certificate, Notarised Affidavit, Notarised will, etc.) I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge regarding the insured to release any information requested regarding this claim and the loss reported. I understand this information will be used by HDFC ERGO General Insurance, or its authorized representatives, for the purpose of evaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim. I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud.

Place: DATE ____/____/____

______________________________________________ SIGNED (Claimant or authorized person)

Accidental Injury Claim Claimant’s Statement

Form ‘A’

INSURED INFORMATION Insured’s Name________________________________ Date of Birth ___/____/____ Marital Status ____ Insured’s Address ________________________________________________________________ Phone No. (Off)_________________________

________________________________________________________________________ Phone No. (Res)______________ Name and address of employer ___________________________________________________________________________________________

Policy Number __________________________ Insured’s Occupation ________________________________________________ Does the insured have any other insurance ? _________If yes, please list all companies, type of insurance, policy numbers and insurance amounts:______________________________________________________________________________________________________________

___________________________________________________________________________________________________________ CLAIM INFORMATION Date of accident _____/_______/_______ Time and place accident occurred______________________________________________________ Please describe in detail the circumstances of accident (attach separate sheet if needed): ___________________________________________ _____________________________________________________________________________________________________________________ Was the accident related to the Insured’s occupation? ___________________ If so, how? __________________________________________ Please describe the nature of Insured’s injuries:_____________________________________________________________________________ Please list the names and addresses of all treating physicians and hospitals:______________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Did police or other authorities investigate the accident? ____ If yes, please provide name, address and telephone number of all investigating officers and agencies: ___________________________________________________________________________________________________

CLAIMANT INFORMATION (If different than “Insured Information” above) Claimant’s Name__________________________________________________________ Age_______ Relationship to Insured______________ Claimant’s Address________________________________________________________________ Phone No. (Off) ________________________ _________________________________________________________________________________ Phone No. (Res)________________________

In what capacity are you making this claim? ________________________________________________________________________________

AUTHORIZATION I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge regarding the insured to release any information requested regarding this claim and the loss reported. I understand this information will be used by HDFC ERGO General Insurance, or its authorized representatives, for the purpose of evaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim. I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. SIGNED (Claimant or authorized person) ___________________________________________________________ DATE ____/____/____

Accidental Injury Claim Claimant’s Statement

Form ‘A’

INSURED INFORMATION Insured’s Name________________________________ Date of Birth ___/____/____ Marital Status ____ Insured’s Address ________________________________________________________________ Phone No. (Off)_________________________

________________________________________________________________________ Phone No. (Res)______________ Name and address of employer ___________________________________________________________________________________________

Policy Number __________________________ Insured’s Occupation ________________________________________________ Does the insured have any other insurance ? _________If yes, please list all companies, type of insurance, policy numbers and insurance amounts:______________________________________________________________________________________________________________

___________________________________________________________________________________________________________ CLAIM INFORMATION Date of accident _____/_______/_______ Time and place accident occurred______________________________________________________ Please describe in detail the circumstances of accident (attach separate sheet if needed): ___________________________________________ _____________________________________________________________________________________________________________________ Was the accident related to the Insured’s occupation? ___________________ If so, how? __________________________________________ Please describe the nature of Insured’s injuries:_____________________________________________________________________________ Please list the names and addresses of all treating physicians and hospitals:______________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Did police or other authorities investigate the accident? ____ If yes, please provide name, address and telephone number of all investigating officers and agencies: ___________________________________________________________________________________________________

CLAIMANT INFORMATION (If different than “Insured Information” above) Claimant’s Name__________________________________________________________ Age_______ Relationship to Insured______________ Claimant’s Address________________________________________________________________ Phone No. (Off) ________________________ _________________________________________________________________________________ Phone No. (Res)________________________

In what capacity are you making this claim? ________________________________________________________________________________

AUTHORIZATION I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge regarding the insured to release any information requested regarding this claim and the loss reported. I understand this information will be used by HDFC ERGO General Insurance, or its authorized representatives, for the purpose of evaluating and determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim. I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. SIGNED (Claimant or authorized person) ___________________________________________________________ DATE ____/____/____

ANNEX - E Declaration from the member bank (on bank’s letter head) (In case nominee details available with the member bank)

This is to hereby confirm that the Mr. / Ms. __________________ was issued a RuPay card vide no. ________________ issued by our bank, and as per the bank records the nominee details of the card holder is as mentioned below along with the NEFT details of the nominee. Card Holder Name: ____________________________ RuPay Card Type: ______________________________ RuPay Card No:_________________________________ Nominee Name:________________________ Relationship with the nominee: _____________________ Bank Account No.: ___________________________ IFSC Code:__________________________ Bank Branch Name:________________________ Bank Address: __________________________________________________________

Authorized signatory Bank seal

Accidental Injury Hospital Cash Claim ( Accident or Sickness)

Form ‘D’

Attending Physician’s Statement INSURED INFORMATION Insured’s Name_________________________________ Date of Birth ____/____/___ Marital Status _____ Insured’s Address_________________________________________________________________ Phone No. (H)_________________________

_________________________________________________________________________ Phone No. (W)________________________ Name and address of employer ___________________________________________________________________________________________

Policy Number_____________________________

Insured’s Occupation ____________________________________________

CLAIM INFORMATION Date of accident: ____/ ____/____

Date of first treatment: _____/_____/_____

Please describe in detail the nature of the Insured’s injuries, _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Was the accident related to the Insured’s occupation? ___________________ If so, how? __________________________________________

Was the Insured hospitalized? _______ If yes, please list the names and addresses of all hospitals and all admission/discharge dates: _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

Did the Insured have any injury or illness prior to the accident that contributed to the accident or to the Insured’s present condition? ____ If yes, please describe: _________________________________________________________________________________________________ _____________________________________________________________________________________________________________________

Were any surgical procedures performed? ______ If yes, please list all procedures, and dates performed: _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ What are the Insured’s current subjective symptoms? _______________________________________________________________________ _____________________________________________________________________________________________________________________ What are the objective findings? (please include results of current x-rays, lab tests, etc.,)? _________________________________________ _____________________________________________________________________________________________________________________

Dates of total disability:

Dates of partial disability:

From: _____/_____/_____ To: ____/____/____

From: _____/_____/______ To: _____/_____/_____

Date Insured able to return to work: _____/_____/_____ Was the Insured seen by any other physician? ______ If yes, please list the names and addresses of all other physicians: ________________ _____________________________________________________________________________________________________________________

ATTENDING PHYSICIAN INFORMATION Name of Attending Physician: _________________________________________________________ Phone No. ________________________ Address: ____________________________________________________________________________________________________________

I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. SIGNED (Attending Physician) ___________________________________________________________ DATE ____/____/____

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Accidental Insurance Claim Form

ANNEX - A Claims Process-RuPay Card for Personal Accident Benefit Policy No - 2999200723397400000 Claim intimation All the claims will intimate to th...

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