Senior Citizen Accident Insurance Claim Form
1. Personal Information
Full Name
Date of Birth
Policy Number
Contact Number
Address
2. Accident Details
Date of Accident
Time of Accident
Location of Accident
Description of Accident
3. Injury & Medical Information
Nature of Injury
Treating Doctor / Hospital Name
Treatment Provided
4. Bank Details (for Claim Payment)
Account Holder Name
Bank Name
Account Number
IFSC Code
5. Declaration
I hereby declare that the information provided is true and correct to the best of my knowledge.
Signature
Date