HDFC ERGO General Insurance Company Limited

Claim Form
Sarv Suraksha Plus (Group)
Claim Form – Part A
To Be Filled In By The Insured
The issue of this Form is not to be taken as an admission of liability

SECTION A – DETAILS OF PRIMARY INSURED

a) Policy No b) Sl. No/ Certificate No:
c) Company/ TPA ID No.:
d) Name
2) Address
City State
Pin Code Phone Mobile
Email ID
SECTION B- DETAILS OF INSURANCE HISTORY
a) Currently covered by any other mediclaim health insurance Yes No

b) Date of commencement of first insurance without break D D M M Y Y Y Y

c) If Yes, Company Name

Policy No.

Sum Insured

d) Have you been hospitalized in the last four years since inception of the contract Yes No D D M M Y Y Y Y

Diagnosis

e) Previously covered by any other Mediclaim/Health insurance Yes No

f) If yes, Company Name

SECTION C- DETAILS OF INSURED PERSON HOSPITALISED

a) Name

b) Relationship(Self/spouse/Child/Father/Mother/Other) c) Date of Birth d) Age Mths/yrs

e) Address (If different than above)

f) Gender Male Female g) Occupation Service/Self-employed/Homemaker/student/
Retired/ Others
h) Telephone No i) Mobile No

j) E-mail ID, if any

SECTION D- DETAILS OF HOSPITALISATION

DD/MM/YYYY
DD/MM/YYYY
HH/MM
DD/MM/YYYY
HH/MM
Self-Inflicted/Road Traffic Accident/ Substance Abuse/ Alcohol Consumption
I) If Medico legal E-mail ID, if any Yes No ii) Reported to police? Yes No
iii) MLC Report, & Police FIR attached? Yes No j) System of medicine Allopathic/Other systems of medicine

SECTION E- DETAILS OF CLAIM

a) Details of the treatment expenses claimed for

b) Section under which claim is made
Version: CLAIM FORM/Ver - 1 MAY 2023

Sec Sub Sec Coverage Yes/ No

A Major Medical Illness
Optional Covers - Major Medical Illness
I Cardiac Arrest
ii Angioplasty
iii Molecular Gene Profiling test
iv Second Medical Opinion
a Second Medical Opinion -India
b Second Medical Opinion -Global

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East),
Mumbai – 400 059. Health Claim Services Address: HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower - 1, 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022 6158 2020/022
6234 6234. Email: healthclaims@hdfcergo.com. UIN: Sarv Suraksha Plus (Group) - HDFHLGP24020V032324.
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 2 Personal Accident
I Accidental Death
A Optional Covers - Accidental Death
I Burns
ii Transportation of Mortal Rem.
iii Renewal Premium Benefit
II Permanent Disablement
III Temporary Total Disablement
i Temporary Total Disability - Accident Only
ii Temporary Total Disability – Illness only
A Optional Cover under Temporary Total Disability – Illness only
i Waiting Period modification Option
3 Emergency Medical Expenses
I Emergency Medical Expenses - Accident Only
II Emergency Medical Expenses - Illness only
A Optional Covers - Emergency Medical Expenses
i Emergency Medical Expenses - Global
ii Co-Payment
4 Loss of Income/EMI Protector
I Termination from Employment
II Loss of Income - Major Medical Illness
A Optional Cover - Loss of Income - Major Medical Illness
i Cardiac Arrest
ii Angioplasty
III Loss of Income - Accidental PTD
5 Credit Shield
i Accidental Death & Permanent Total Disablement
6 Property Coverage
I Fire & Allied Perils
A Optional Covers - Fire & Allied Perils
i Earthquake
ii Terrorism
II Burglary
7 Broken Bones
8 Dependent Child Education Benefit
9 Parental Care Benefit
10 Mobility Extension
I Mobility Extension - Benefit
II Mobility Extension – Indemnity
11 Hospital Cash
I Hospital Cash - Accident Only
II Hospital Cash – Illness only
A Optional Covers - Hospital Cash
I Companion Benefit
I Hospital Cash - ICU
ii Time Deductible modification Option
iii Hospital Cash - Global
iv Waiting Period modification option (applicable to Hospital Cash -Illness only)
12 Chauffeur Benefit
13 Accidental Hospitalization Expenses
A Optional Covers - Accidental Hospitalization Expenses
i Post Hospitalization expenses
ii Hospitalization Expenses - Global
iii Co-Payment
14 Permanent Total Disablement - Illness
15 Last Rites

Optional Covers
S.No. Cover Yes/No
1 Preventive Health Checkup
2 Medical Evacuation
3 Road Ambulance

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East),
Mumbai – 400 059. Health Claim Services Address: HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower - 1, 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022 6158 2020/022
6234 6234. Email: healthclaims@hdfcergo.com. UIN: Sarv Suraksha Plus (Group) - HDFHLGP24020V032324.
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 c) Please provide the below details
i) Critical Illness /Surgeries Please mention the Critical Illness/Surgeries claimed for:
ii) Hospital Cash Please mention the no of days, benefit claimed for

SECTION – F DETAILS OF BILLS ENCLOSED

Sr.no. Bill No. Date Issued By Towards Amount (Rs)
D D M M Y Y Y Y

SECTION – G DETAILS OF PRIMARY INSURED’S BANK ACCOUNT

a) Payee Name b) Account Number
c) Bank Name/ Branch d) Payable details: Cheque/ DD
e) IFSC Code e) *please attach a cancelled cheque pertaining to the same

f) MICR No *please attach a cancelled cheque pertaining to the same

g) PAN
Note:
It is agreed that the Policyholder/Claimant will intimate in writing to HDFC ERGO General Insurance Co. Ltd. about any change in bank account details.
In an event Insured person bears expenses for treatment please provide account details of Insured Persons in the above format along with proof of incurring such expenses..

SECTION H – DECLARATION BY THE INSURED

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any
material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical
information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the
purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.

Date: D D M M Y Y Y Y Place:______________ Signature of Insured

LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

Note:
1. When original bills, receipts, prescriptions, reports and other documents are submitted to the other insurer or to the reimbursement provider, verified photocopies attested by such other
organization/provider have to be submitted.
2. If original bills, receipts, prescriptions, reports and other documents are submitted to Us and Insured Person requires same for claiming from other organization/provider, then on request from the Insured
Person We will provide attested copies of the bills and other documents submitted by the Insured Person.
3. If below mentioned documents are not provided in full or are insufficient for Us to consider the claim, then We may request additional information or documentation.

Claim Documents for all the health Covers

Claims Documents to be submitted for 1. Duly filled Claim Form with signature of claimant.
Major Illness and Permanent Total 2. Copy of Discharge Summary / Discharge Certificate / Death Certificate (in case insured expired);
Disablement due to Illness. 3. First consultation letter from treating Medical Practitioner
4. Medical certificate confirming diagnosis, and the treatment from Medical Practitioner
5. certificate from treating Medical Practitioner, specifying the duration and etiology
6. OT Notes in case of Surgery
7. Medical certificate from treating Medical Practitioner specifying the diagnosis and need for the surgery
8. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
9. All pathological/Histopathological and radiological Investigation Reports
10. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide legal heir certificate in case nominee is minor.
11. Provide KYC ( Know your customer ) form along with photocopy of any one of following KYC documents for all claims amounting to Rs 1 lakh
and above (Aadhar Card, Passport, Driving License Voter ID, etc.)
12. Other necessary document as required by the Company
We may require the Insured Person to undergo medical examination by Medical Practitioner authorized by Us to obtain an independent medical
opinion for the processing of the claim. Any cost towards such medical examination will be borne by Us.

1. Duly filled claim form along with the copy of all medical reports including investigation reports and discharge summary (if any)
Claims documents and procedure for 2. Select Our network Medical Practitioner from whom you would prefer to take the second opinion. (Please refer our Website or call at 24X 7 toll
Second Opinion free line to obtain the list of Our panel doctors).
3. On receipt of the complete set of documents, We will forward the same to the concerned doctor.
4. The Second Opinion shall be forwarded to the member within 15 working days of receipt of the complete set of documents.
5. Where Claim is on reimbursement basis – Diagnostic report and invoice from Medical Practitioner

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East),
Mumbai – 400 059. Health Claim Services Address: HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower - 1, 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022 6158 2020/022
6234 6234. Email: healthclaims@hdfcergo.com. UIN: Sarv Suraksha Plus (Group) - HDFHLGP24020V032324.
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 Claims Documents to be submitted for 1. Duly completed claim form;
Loss of Income due to termination 2. Certificate if applicable from the Bank stating the amortization schedule, the EMI Amounts, Principal Outstanding, etc.
3. Certificate from the employer of the insured confirming the termination with date of and period of termination.
4. Form 26 AS
5. Any other necessary document as may be required by the Company.
6. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide legal heir certificate in case nominee is minor.

Claims Documents to be submitted for 1. Duly completed claim form;

Loss of Income due to resignation due to CI 2. Certificate if applicable from the Bank stating the amortization schedule, the EMI Amounts, Principal Outstanding, etc.
3. Resignation Letter/ Resignation Acceptance letter
4. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide legal heir certificate in case nominee is minor.

Claims Documents to be submitted for 1. Duly filled Claim Form with signature of claimant.
Loss of Income due to resignation due to 2. Copy of Discharge Summary / Discharge Certificate
Accidental Permanent Total Disablement 3. First consultation letter from treating Medical Practitioner
4. Certificate from treating Medical Practitioner, specifying the duration and etiology
5. OT Notes in case of Surgery
6. Medical certificate from treating Medical Practitioner specifying the diagnosis and need for the surgery
7. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
8. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide legal heir certificate in case nominee is minor.

Claims documents to be submitted for 1. Medical Practitioner’s Report

Accidental Death 2. Medico Legal Certificate
3. Death certificate
4. Post mortem if conducted/FSL (Forensic science laboratory)report – To check for drug abuse/intoxication
5. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable

Claims documents to be submitted for 1. Medical Practitioner’s Report

Permanent Disablement 2. Medico Legal Certificate
3. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the Injury;
4. Disability certificate from a government certified Medical Practitioner or government Hospital confirming the extent and nature of disability;
5. Discharge summary from the Hospital Medical reports, case histories, investigation reports, treatment papers as applicable.
6. Letter from treating Medical Practitioner mentioning the reason and date for disablement and confirming the disablement.
7. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable

Claims documents to be submitted for 1. Medical Practitioner’s Report

Temporary Total Disablement 2. Medico Legal Certificate
3. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the Injury;
4. Discharge summary from the Hospital
5. Medical reports, case histories, investigation reports, treatment papers as applicable.
6. Letter from treating Medical Practitioner mentioning the reason and date for disablement and confirming the disablement. And advised days of rest.
7. Leave certificate from the employer (If Employed)
8. Fitness certificate from Medical practitioner
9. Insured's own Indian bank cancelled cheque copy and bank details in attached format
10. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable

1. Copy of Discharge Summary / Discharge Certificate along with time of admission and discharge for Hospital cash benefit
Claims documents to be submitted for
2. First consultation letter from treating Medical Practitioner
Hospital Cash
3. Certificate from treating Medical Practitioner, specifying the duration and etiology
4. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
5. NEFT details & cancelled cheque of Claimant or Nominee (in case claimant expired), Provide legal heir certificate in case nominee is minor.

Claims documents to be submitted for 1. Medical Practitioner’s Report

Broken Bones 2. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the Injury;
3. Disability certificate from a government certified Medical Practitioner or government hospital confirming the extent and nature of disability;
4. Original Discharge summary from the hospital
5. Medical reports, case histories, investigation reports, treatment papers as applicable.
6. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
7. Relevant treatment papers clearly mentioning the areas of fracture with their severity.

Claims documents to be submitted for 1. Consultation note or Emergency Room's Medical Practitioner medical report
Medical Evacuation 2. Copy of the passport showing the date of entry and exit related to journey (to & fro) from India.
3. All relevant Original Invoices for the expenses incurred towards ambulance facility.
4. A covering letter from claimant mentioning the details of loss.

Claims documents to be submitted for 1. Consultation note or Emergency Room's Medical Practitioner medical report.
Emergency Medical Expenses and 2. Relevant treatment papers or Discharge Summary.
Accidental Hospitalization 3. Copy of the passport showing the date of entry and exit related to journey (to & fro) from India.
4. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable
5. All relevant Original Invoices for the expenses incurred.

Claims documents to be submitted for 1. Consultation Note OR Emergency Room's Medical Practitioner medical report OR
Dependent Child Education Benefit and 2. Relevant Treatment Papers OR Discharge Summary. .
Parental Care Benefit 3. Letter from treating Medical Practitioner, mentioning the cause of death if death occurred after a long period from the date of incident.
4. Disability certificate from a government certified Medical Practitioner or government hospital confirming the extent and nature of disability;
5. Death certificate
6. Final police investigation report
7. Post-mortem Report or Coroner’s Report
8. MLC/FIR copy/ certificate regarding abuse of Alcohol/intoxicating agent if applicable.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East),
Mumbai – 400 059. Health Claim Services Address: HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower - 1, 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022 6158 2020/022
6234 6234. Email: healthclaims@hdfcergo.com. UIN: Sarv Suraksha Plus (Group) - HDFHLGP24020V032324.
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 Claims documents to be submitted for 1. Duly completed and signed claim form.
Mobility Extension Cover 2. Policy/Certificate Copy
3. Expenses incurred towards supporting equipment (wheel chair, railings, customized motor vehicle)
4. Consultation Note Or Emergency Room's Medical Practitioner medical report OR Relevant Treatment Papers OR Discharge Summary.
5. All relevant Invoices for the expenses incurred.
6. Letter from treating Medical Practitioner mentioning the reason for disablement and confirming the disablement.
7. Details of home, office and /or vehicle or towards purchase of an Artificial limb/wheelchair/or any limb during claim processing

Claims documents to be submitted for 1. Medical Practitioner’s Report

Chauffeur Benefit 2. Medico Legal Certificate
3. Investigation Reports like Laboratory test, X-rays and reports essential of confirmation of the Injury;
4. Original Discharge summary from the Hospital
5. Medical reports, case histories, investigation reports, treatment papers as applicable.
6. Letter from treating Medical Practitioner mentioning the reason and date for disablement and confirming the disablement.
7. Original invoices of transport

Claims documents to be submitted for 1. Claim Form, duly completed

Last Rites Cover 2. Death certificate

Claims documents to be submitted for Burns 1. Attested copy of certificate from treating Medical Practitioner specifying type of burns with percentage of burns
2. Attested copy of FIR. (If any)
3. All X-Ray / Investigation reports and films supporting to disability.

Claim Documents for Property cover:

Documents required for processing of 1. Policy/Underwriting documents.

claim 2. Survey Report with Photographs
3. Claim Form, duly completed.
4. Log book / Asset register / Capitalized item list
5. Repair / Replacement invoices with receipt
6. All Applicable valid Certificates

Customer Identification Procedure (as per KYC norms of IRDAI)

Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used (Any one of the mentioned documents) Passport/ PAN Card/ Voter’s Identity Card/ Driving License/ Letter from a recognized public authority
or public servant verifying the identity and residence of the customer
Proof of Residence (Any one of the mentioned documents) Telephone bill/ Bank account statement/ Letter from any recognized public authority/ Electricity bill/
Ration card

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East),
Mumbai – 400 059. Health Claim Services Address: HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower - 1, 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022 6158 2020/022
6234 6234. Email: healthclaims@hdfcergo.com. UIN: Sarv Suraksha Plus (Group) - HDFHLGP24020V032324.
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