Claim Form For Janata Personal Accident Insurance Policy

THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd & Head Office : New India Assurance Building,
87, Mahatma Gandhi Road, Bombay – 400 001

JANATA PERSONAL ACCIDENT INSURANCE POLICY CLAIM FORM

The issue of this form is not to be taken as an Admission of liability
CLAIM NO._____________________________________________

SECTION I (TO BE FILLED IN FOR ALL CLAIMS)

1. (a) Insured’s Name __________________________________

(b) Address: ____________________________________
____________________________________
____________________________________
____________________________________

(C) Age: ____________________________________

2. (a) Policy No. ________________________________________
(b) Period From ________________to ____________________
(c) Issued at _________________________________________

3. (a) Particulars of accident: Date Time Place
Whether reported to Police Yes/No
(b) Details

4. (a) Were you removed to hospital immediately after the accident? Yes/No
(b) If yes, address of the hospital

5. (a) Do you have any other Janata Personal Accident Policy? Yes/ No
(i) If yes, Name of the company: _________________
(ii) Policy No.: ________________________________
(iii) Period ____ yrs From __________ to _____________
(iv) Issued at: ______________________________
(b) Are you entitled to recover medical/hospitalisation expenses under any other
medical/hospitalisation scheme?
If yes, (i) Nature of scheme:
(ii) Amount paid or payable:

SECTION II (TO BE FILLED IN BY HOSPITAL AUTHORITIES)

1. Name and address of the hospital: __________________________________
______________________________________________________________

2. Date of admission: ______________________________________________
3. Date of Discharge: _________________________________________________
4. (a) Nature of injury: ________________________________________________
(b) Particulars of treatment: __________________________________________
5. Has the accident resulted into loss of hand/s or foot/feet or eye/s permanent disability of any other type which may prevent the insured from engaging in or being occupied with or giving attention to any employment or occupation whatsoever?
If yes, please give details
6. Hospital expenses (Please attach original bills)

Date ____________
Rubber Stamp of Hospital Signature of the Competent Authority
Of Hospital/Nursing Home

Designation ______________

SECTION III (TO BE COMPLETED BY NOMINEE IN THE EVENT OF INSURED’S DEATH)

Details of Nominee
(a) Full Name: __________________________________________________
(b) Address: ____________________________________________________
____________________________________________________________
(c) Age: ________________________________________________________
(d) Relationship with the deceased: ___________________________________

Date: _____________ _______________________________
Signature of the Nominee

Please attach the following documents:
1. Death certificate
2. Post Mortem Report
3. Original Policy document with receipt

Declaration to be signed by the Insured/Claimant or by a Nominee (in the event of insured’s death)

I/WE HEREBY DECLARE and warrant the truth of the foregoing particulars in every respect. I/WE agree that if I/WE have made, or if, shall make false or untrue statement, suppression or concealment, my/our right to compensation shall be forfeited.

I/WE ALSO HERE DECLARE that I am /we are accepting the amount in full discharge of your obligations under the policy to the insured and/or his/her legal heirs and I/WE will hold you indemnified in the event of any claim under this policy being made against you by any other person or persons.

Date ______________ Signature ________________________