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    Tata-Aig General Insurance Company LTD: Policy No. 0238443404 / 0238443469 Claim No.

    Uploaded by

    Mahendra Singh
    1. This is a claim form for a personal accident insurance claim for RuPay cardholders with TATA-AIG General Insurance Company. 2. It requires details of the insured/claimant such as name, address, occupation, age, type of RuPay card held and account number. 3. It also requires details of the accident such as date, location, cause and nature of injuries. Treatment details from doctors and hospitals are to be provided. 4. The claimant is required to declare that the details provided are true and correct, and authorize the insurance company to obtain relevant documents.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Tata-Aig General Insurance Company LTD: Policy No. 0238443404 / 0238443469 Claim No.

    Uploaded by

    Mahendra Singh
    75 views3 pages
    1. This is a claim form for a personal accident insurance claim for RuPay cardholders with TATA-AIG General Insurance Company. 2. It requires details of the insured/claimant such as name, address, occupation, age, type of RuPay card held and account number. 3. It also requires details of the accident such as date, location, cause and nature of injuries. Treatment details from doctors and hospitals are to be provided. 4. The claimant is required to declare that the details provided are true and correct, and authorize the insurance company to obtain relevant documents.

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    Original Title

    Claim Form

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    1. This is a claim form for a personal accident insurance claim for RuPay cardholders with TATA-AIG General Insurance Company. 2. It requires details of the insured/claimant such as name, address, occupation, age, type of RuPay card held and account number. 3. It also requires details of the accident such as date, location, cause and nature of injuries. Treatment details from doctors and hospitals are to be provided. 4. The claimant is required to declare that the details provided are true and correct, and authorize the insurance company to obtain relevant documents.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    75 views3 pages

    Tata-Aig General Insurance Company LTD: Policy No. 0238443404 / 0238443469 Claim No.

    Uploaded by

    Mahendra Singh
    1. This is a claim form for a personal accident insurance claim for RuPay cardholders with TATA-AIG General Insurance Company. 2. It requires details of the insured/claimant such as name, address, occupation, age, type of RuPay card held and account number. 3. It also requires details of the accident such as date, location, cause and nature of injuries. Treatment details from doctors and hospitals are to be provided. 4. The claimant is required to declare that the details provided are true and correct, and authorize the insurance company to obtain relevant documents.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    TATA-AIG GENERAL INSURANCE COMPANY LTD

    Address: A-501,5Th Floor, Bldg No -4, Infinity Park, Dindoshi,


    Malad (East), Mumbai – 400 097

    Personal Accident Insurance Claim form


    For RuPay Cardholder’s
    IMPORTANT
    1. Issuance of this form is not an admission of Liability or a waiver of the terms, conditions and exceptions of
    the insurance contract.
    2 .No claim will be admitted without a Medical Report as per format to be obtained at claimant's expense. 3.
    Claim form for Accidental Death/Dismemberment of RuPay Platinum / Select Cardholder’s (To be submitted
    at the Branch)

    Policy No. 0238443404 / 0238443469 Claim No. _

    1 PERSONAL DETAILS

    Name of RuPay Cardholder

    Address City
    State _ PIN

    Occupation
    Age

    Type of RuPay Card held (please tick):


    Bank Account No:
    RuPay Platinum Card
    RuPay Card No :
    RuPay Select Card

    Date of Last Transaction:


    Nature of Transaction:
    Any other RuPay Card held by the same person : YES / NO
    (If Yes please give details) :

    2 CLAIMANT (NOMINEE) DETAILS (Mandatory for Death claims)

    Name of the Nominee (Claimant)


    (As per Bank Records)
    Address
    City State
    PIN
    Relationship with deceased customer
    Mobile Number & Email id _

    3 BRANCH DETAILS (FOR CUSTOMER)

    Bank Name
    Name of Branch
    Address
    City State
    PIN
    IFSC code of Branch
    Name of Branch Contact
    Mobile Number
    Email id
    4 DETAILS OF ACCIDENT
    Nature of claim DEATH / DISABLEMENT / DISMEMBERMENT

    Date of Incident _
    Date of Death (if applicable) _
    Place and Location (Full Address)

    Cause Description

    5 DETAILS OF INJURIES
    Specify Injured / dismembered Parts of Body ----------------------------------
    ----------------------------------------------
    Total Disablement (if any) ----------------------------------------------
    Percentage -------(%) ------------------------------(In Words)

    6 WITNESSES
    1) Name 2) Name
    Address Address

    Contact No. Contact No

    7 TREATMENT DETAILS
    A Casualty Doctor
    Name ----------------------------------------------

    Address ----------------------------------------------
    Phone ----------------------------------------------
    Registration No ----------------------------------------------

    B Hospital(s) if Hospitalized
    Name ---------------------------------------------

    Address ---------------------------------------------
    Phone No ---------------------------------------------

    8 AMOUNT OF CLAIM

    A Permanent Disablement Amount (Rs)--------------

    B Death Amount (Rs)--------------

    9 PAST HISTORY
    A Have you made any claims in the PAST with TATA AIG or other insurance company?
    YES/NO

    B If YES, please give details including accident and Insurance details

    I hereby declare that I have suffered injuries as described above and all the details given are ABSOLUTELY TRUE
    AND CORRECT.I hereby agree to forfeit all my rights to compensation if any of the foregoing facts and /or details
    are found to be false or incorrect. I further authorize the hospital, doctor diagnostic laboratory, organization,
    establishment or any other body or person dealt with in the course of this claim to give any information or document
    sought for by the Insurance Company.

    Signature of the Insured/Claimant Signature of Incumbent with branch Seal

    Date:
    Place:

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