Group Personal Accident Insurance Claim Form
1. Policy Details
Policy Number
Employer/Group Name
Member/Employee Name
Member/Employee ID
2. Claimant Details
Full Name
Date of Birth
Contact Number
Email
Address
3. Accident Details
Date of Accident
Time of Accident
Location of Accident
Describe How the Accident Occurred
4. Nature of Injury
Type of Injury
Part(s) of Body Injured
Treatment Details
5. Hospital/Doctor Details
Name of Hospital/Doctor
Address
Contact Number
6. Bank Details (for Claim Payment)
Account Holder Name
Bank Name
Account Number
IFSC Code
7. Declaration
I hereby declare that the information provided above is true and correct to the best of my knowledge.
Place
Date
Signature