HDFC ERGO ACCIDENTAL INJURY CLAIM FORM_APPHC and

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Personal Accident Insurance How to file a Claim •

In case of any event leading to a claim under the policy, please call our Toll-free Number 1800-2-700-700



Our Claims Service Representative will guide you on the claim procedures and documents Required



Complete the claim form relevant to the nature of loss as indicated below.



Attach the documents mentioned against the claim type

For Accidental Injury Claims

1. 2. 3. 4. 5. 6.

• •



Claim form as per ‘Form A+ D’ Police FIR, if accident is reported to Police Medical papers, pathology reports, X-ray reports, as applicable For Permanent Disability Claims – disability certificate from reputed surgeon or Municipal Hospital For Temporary Total Disability Claims-sick leave certificate from Employer Attending Physician’s statement as per ‘Form D’

Our Claims Service Representative may visit you in the Hospital or at Home to personally collect claim documents. Documents, in addition to those mentioned above maybe called for, depending on the nature of accident and claim lodged. Please retain a copy of the documents sent for your records.

Accidental Injury Claim

Form ‘A’

Claimant’s Statement

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

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 permanent total disability: From: _____/_____/_____ To: ____/____/____

Dates of temporary total disability: 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. SIGN WITH STAMP (Attending Physician) ___________________________________________________________ DATE

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HDFC ERGO ACCIDENTAL INJURY CLAIM FORM_APPHC and

Personal Accident Insurance How to file a Claim • In case of any event leading to a claim under the policy, please call our Toll-free Number 1800-2-7...

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