This form can be used when you want to file for a Claim of an Accident according to the Policy guidelines. Fill and submit this form to the Bajaj Allianz Cliam Office along with all the required documents.
Regd. Office: Bombay Pune Road, Akrudi, Pune 411 035 & Head Office: GESCO Plaza, Airport Road, Yerawada, Pune 411 006
GROUP PERSONAL ACCIDENT INSURANCE
CLAIM FORM
Policy
No
Claim No.
Date of registration
Regional/Branch Office Code
Broker/Agent Code1. Name of the Insured
2. Customer ID
3. Address of the Insured Plot No/Door
No.
Building
name
Road
Area
City Pin code
State
Phone No.
E-mail Id
4. Profession or Occupation
Policy details
Sum Insured Table of Cover
5. a)Name of the insured person died/
injured in the accident
b) Relationship with the employee/ member
c) Employee/member identification no. Self/Spouse/Children
6. a) Date of the Accident
b) Time of the Accident
c) Where it happened?
d) Name & Address of the Witness
7. How did the Accident occur?
8. Nature of Injury received (if to limb or
Eye state whether right or left)
9. a) Nature of disablement
b) Extent of disablement
c) Period of temporary total disablement
d) Present state of incapacity
(From……………to….………)
10. Name and address of Surgeon in attendance
11. Where and when can a Medical Officer
of our Company visit you, if
necessary?
12. a) Are you insured in any other Office or
Off ices granting compensation for
accident?
b) If so state name and address of company or
Companies and amount of InsuranceI/We hereby declare that the foregoing statements are true in all respects and that I/We have not
attempted to conceal from the company anything with which it ought to be made acquainted and
also that if I/We have made or in any further declaration the Company may require shall make any
false or fraudulent statement or any suppression, concealment or untrue averment whatever, the
Policy shall be void and my/our right to compensation forfeited and am/are willing if required, to
make a statutory Declaration before a Justice of the Peace of the truth of the whole of the foregoing
statement or any other statement I/We ma y make in connection with this claim.Witness:
Name………………………………
Signature …………………………
Signature of the Insured……………………
Date …………
MEDICAL CERTIFICATE(Claim must be supported by the Medical Evidence furnished by the Ins ured at his/her expense)
1. a) Name of Claimant
(b) Age
1.
a) Nature and cause of Accident
b) If to eye or limb, state left or rightc) Whether the appearance of the injuries
are consistent with the account given
of the accident
2.
Date on which you first attended claimant for this injury
3.
Has claimant been totally prevented from attending to
any portion of his business? If so for how long?
4.
Is claimant suffering from any disease or illness apart from
his injury and is there any illne ss by circumstances which
may tend to retard recovery? If so, give particulars
5.
Present condition
6.
How long from the happening of the Accident do you consider
a) Total disablement will last
b) Partial disablement will last
Having personally examined the above named Insured, I certify that the above statements are
correct and that the injured person is necessarily disabled by the accident referred to.Signature:
Name:
Qualification:
Address: