HDFC ERGO General Insurance Company Limited
Overseas Travel Insurance Claim Form
(To be filled in by the Insured Policyholder or Insureds Representative duly authorised by Power of Attorney. Issuance of this claim form is not to be taken as an admission of liability. Please attach all bills, receipts, credit
card slips pertaining to your claim)
Please contact our 24x7 helpline in respect to any claims settlement request. Contact Details for Travel Claims.
Landline - + 91 - 120 - 4507250 (Chargeable)
Toll free No - + 800 08250825
Email ID - travelclaims@hdfcergo.com
Period from: ____/____/____ to ____/____/____
POLICY/CERTIFICATE NO. __________________________________
Passport No _______________________
Trip Destination _______________________
Claims Ref No ________________________________
DETAILS OF INSURED
Name:
Date of Birth:
Sex
Male
Female
Current Address:
Phone No. (Res)
Email Id.
Permanent Address:
Phone No. (Off)
Phone No. (Res)
Does the insured have any other Health/Accident or Travel Insurance ? If yes, please give details below:
Name of Insurer:
Policy Number:
Date trip commenced ______/____/_____
Schedule date of return ______/____/_____
CLAIMANT INFORMATION (If different than Insured Information above, Name and Age of each person included in the claim)
Name:
Date of Birth:
Claimants Address
Phone No. (Off)
Phone No. (Res)
Relationship with the Policyholder:
In what capacity are you making this claim?
Please indicate whether claim is in respect of ( Tick Boxes)
Accidental Death
Permanent Disablement
Body Repatriation (Related to Death Cover)
Emergency Hotel Accommodation
Emergency Medical Expenses & Medical Transport/Evacuation
Emergency Travel Expenses for Family Members
Loss of Baggage & Personal Documents
Trip Cancellation (Cancellation of to & Fro Journey)
Emergency Dental Benefits
Hospital Cash - Accident Only
Emergency Travel Expenses for Replacement Colleague
Loss of Checked in Baggage
Trip Interruption (Cancellation of Return Journey)
Delay of Checked in Baggage
Personal Liability
Emergency Hotel Extension
Flight Delay
Loss of Cash
Hijacking
Other (Pls specify)
AUTHORIZATION
I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge regarding the insured to release any
information requested regarding this claim and the loss reported. I understand this information will be used by HDFC ERGO General Insurance, or its authorized representatives, for the purpose of evaluating and
determining coverage for this claim. I know I have a right to receive a copy of this authorization upon request and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this
authorization shall be valid for the duration of this claim.
I also authorise services provider of HDFC ERGO to obtain any medical records or information to process this claim.
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution
for insurance fraud.
I/We hereby understand, declare, consent and authorise the Company that personal health details, medical history and financial information, as provided to the Company may be utilised for processing the claim made
under the Policy. I/We hereby also understand, declare and consent that the Company shall have right to retain and disseminate the same to any service provider for providing services related to insurance.
PLACE______________ DATE ____/____/____
SIGN (Claimant or authorized person)
N.B. Please complete appropriate section of Claim Form and read carefully the instructions relating to supporting documents required. When completed please sign declaration above
Section A Accidental Injury Form (Claimants Statement)
Date of accident ______/______/______
Time________________
Place of Accident ______________________________
Please describe in detail the circumstances of accident (attach separate sheet if needed)
Please describe the nature of Insured s injuries
Please list the names and addresses of all treating physicians and hospitals:
Name
Street Address
City
State
Pin Code
Phone
Did police or other authorities investigate the accident? ____ If yes, please provide name, address and telephone number of all investigating officers and agencies:
Registered & Corporate Office: 1st Floor, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai 400 020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri
(E), Mumbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com CIN : U66010MH2002PLC134869 IRDA Reg No. 125.
Section B - Accidental Injury/Emergency Medical Expenses/Emergency Dental Expenses (Insureds Statement)
Name/Nature of Sickness or Injury:
Date of Sickness/Injury ____/____/____
Place of Sickness/Injury:
Circumstances of Sickness/Injury?
Type of claim -
cashless
reimbursement
both
Please list the names and addresses of all treating physicians and hospitals:
Name
Details of Claimed Expenses
Address
Phone No.
Admitted on
Amount Charged in local currency (which currency)
Discharged on
Has bill been paid by you? Yes/No
Total
Section C Accidental Injury /Medical Expenses Claim /Dental Expenses (Attending Physicians Statement)
Date of accident/sickness ____/____/____
Date of first treatment ____/____/____
Yes/No
Please describe in detail the nature of the Insureds injuries
Was the Insured hospitalized? _______ If yes, please list the names and addresses of all hospitals and all admission/discharge dates
Did the Insured have any injury or illness prior to the accident that contributed to the accident or to the Insureds present condition? If yes, please describe
Were any surgical procedures performed? ______ If yes, please list all procedures, and dates performed
What are the Insureds current subjective symptoms?
What are the objective findings? (please include results of current x-rays, lab tests, etc.,)?
Dates of total disability From ____/_____/____ To ____/_____/____
Dates of total partial From ____/_____/____ To ____/_____/____
Date Insured able to return to work____/_____/____
Was the Insured seen by any other physician? ______ If yes, please list the names and addresses of all other physicians
ATTENDING PHYSICIAN INFORMATION
Name of Attending Physician
Address
Phone
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution
for insurance fraud
PLACE______________ DATE ____/____/____
SIGN (Attending Physician)
Registered & Corporate Office: 1st Floor, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai 400 020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri
(E), Mumbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com CIN : U66010MH2002PLC134869 IRDA Reg No. 125.
Section D - Checked Baggage Loss/ Baggage Delay/ Baggage and Personal Document Loss Information
Date of loss, damage or delay ____/____/____
Time of day ________a.m ________p.m
Please describe in detail where and how the loss, damage or delay occurred
Please describe in detail the nature and extent of loss, damage or delay
Was loss, damage or delay occurred while insured property was on or in the custody of a common carrier (e.g., railroad, airline, cruise ship, bus, taxi, etc.) ?
Yes
No
If yes, please complete the following
Name of carrier:
Flight, trip our tour number:
Was the carrier notified at the time of loss or damage?
Yes
No
If yes, please identify where, when and to whom (name and title) notification was given
Was extra valuation of the property declared? ______________ If yes, how much?
Was the baggage checked at the time of loss or damage?
Yes
No
If yes, please enclose claim check
Yes
Has formal claim been filed against the carrier?
If yes, has payment been made to you?
Yes
No
No
If yes, amount received?
Do you have any other insurance that may provide coverage for this accident or loss?
Yes
No
If yes, please identify the name, address and policy number of all other insurance including Homeowners Travel club, credit card etc
Has the claim been filed?
Yes
No
If yes, what is the current status of that claim?
Was loss reported to police or other authorities?
Yes
No
If yes, please identify where, when and to whom (name and title) loss was reported
Case # ________________________
Valuation of lost and/or damage property
Sr. No
Description
Date and place of Purchase
Original Cost
Replacement Cost or Estimated
Amount Claimed
1.
2.
3.
4.
5.
6.
7.
(attach bills of sale, receipts or estimates)
Are any claims items used in your business/ occupation or profession? _____. If yes, identify the items by * above
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution
for insurance fraud
PLACE______________ DATE ____/____/____
SIGN (Claimant or authorized person)
Registered & Corporate Office: 1st Floor, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai 400 020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri
(E), Mumbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com CIN : U66010MH2002PLC134869 IRDA Reg No. 125.
Section E - Flight Delay/ Flight Cancellation Claim Information
Name of the common carrier
Flight No:
From _____/ _____/ _____ To _____/ _____/ _____ a.m./ p.m.
Please describe in detail the nature and extent of loss, damage or delay
Was loss, damage or delay occurred while insured property was on or in the custody of a common carrier (e.g., railroad, airline, cruise ship, bus, taxi, etc.) ?
Yes
No
If yes, please complete the following
Name of carrier:
Flight, trip our tour number:
Was the carrier notified at the time of loss or damage?
Yes
No
If yes, please identify where, when and to whom (name and title) notification was given
Was extra valuation of the property declared?
If yes, how much?
Yes
Was the baggage checked at the time of loss or damage?
No
If yes, please enclose claim check
Has formal claim been filed against the carrier?
If yes, has payment been made to you?
Yes
Yes
No
No
If yes, amount received:
Do you have any other insurance that may provide coverage for this accident or loss?
Yes
No
If yes, please identify the name, address and policy number of all other insurance including HomeownersTravel club, credit card etc
Has the claim been filed?
Yes
No
If yes, what is the current status of that claim? _________________________________________________________________________________________________
DETAILS OF EXPENDITURE INCURRED
Sr. No
Description
Date
Place
Amount
1.
2.
3.
4.
5.
6.
Total
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution
for insurance fraud
SIGN (Claimant or authorized person)
Claims not falling in the above mentioned sections
Type of claim:
Incidence of claim description:
Place of loss ____________________________
Claim Number: ________________________
Date of loss _____/_____/______
Claimed amount _______________________
Policy Number: ________________________
I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution
for insurance fraud.
PLACE______________ DATE ____/____/____
SIGN (Claimant or authorized person)
Registered & Corporate Office: 1st Floor, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai 400 020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri
(E), Mumbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com CIN : U66010MH2002PLC134869 IRDA Reg No. 125.
Insurance is the subject matter of solicitation. Form No. 391.
PLACE______________ DATE ____/____/____
HDFC ERGO General Insurance Company Limited
Consent for Mode of Claim Payment
Name of Insured
Policy Number
Claim Number
Beneficiary Name
Mode of Payment
Cheque
Fund Transfer
(Please tick for mode of payment)
(All Fields are Mandatory in case of Fund Transfer)
Insureds Name as per
Bank Account
Bank Account Number
Branch Name
IFSC Code
Attachments
In Support of Bank Details
(Please tick the type of proof submitted)
Email address
Cancelled Cheque
Bank Passbook Copy
Declaration: I Mr./ Mrs/ Ms. ______________________________________________________________________________________
undersigned, legal beneficiary of the above claim, declare that all details mentioned in this form are true and I agree to the mode of payment
against the particular claim number mentioned above.
Signature of Beneficiary
Date:
M M
Stamp Required in case of Company
Registered & Corporate Office: 1st Floor, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai 400 020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri
(E), Mumbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com CIN : U66010MH2002PLC134869 IRDA Reg No. 125.
