(To be filled in by the Insured Policyholder or Insured’s 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). *Photocopy of Adhar Card /Adhar Card number is mandatory for all claims
 
Please contact our 24x7 helpline in respect to any claims settlement request. Contact Details for Travel Claims.
International Toll free No - + 800 08250825 (When dialing from abroad)
Email ID - travelclaims@hdfcergo.com
Landline - + 91 - 120 - 4507250 (Chargeable)
(When dialing from India)
 
Click on "Generate PDF" button and save the filled form in your desired folder.
POLICY/CERTIFICATE NO.
 
Period from: to
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:
Claimant’s 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 Emergency Medical Expenses & Medical
      Transport/Evacuation
Emergency Dental Benefits Hospital Cash - Accident Only Body Repatriation (Related to Death Cover)
Emergency Travel Expenses for
      Family Members
Emergency Travel Expenses for
      Family Replacement Colleague
Emergency Hotel Extension
Emergency Hotel Accommodation Loss of Baggage & Personal Documents Loss of Checked in Baggage
Delay of Checked in Baggage Flight Delay Hijacking
Trip Cancellation (Cancellation of
      Family Replacement to & Fro Journey)
Trip Interruption (Cancellation of
      Family Replacement Return Journey)
Personal Liability
Loss of Cash 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
 
 
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 (Claimant’s 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 Pincode Phone
Did police or other authorities investigate the accident? If yes, please provide name, address and telephone number of all investigating
officers and agencies:
 

Section B - Accidental Injury/Emergency Medical Expenses/Emergency Dental Expenses (Insured’s 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 Address Phone No. Admitted on Discharged on
Details of Claimed Expenses Amount Charged in local currency (which currency) Has bill been paid by you? Yes/No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Total  
 

Section C – Accidental Injury /Medical Expenses Claim / Dental Expenses (Attending Physician’s Statement)

Date of accident/sickness
 
Date of first treatment
 
Yes/No  
Please describe in detail the nature of the Insured’s 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 Insured’s present condition? If yes, please describe
Were any surgical procedures performed? If yes, please list all procedures, and dates performed
What are the Insured’s 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 To
   
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
   
 

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
Has formal claim been filed against the carrier? Yes    No
If yes, has payment been made to you? Yes    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
   
 

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?
Was the baggage checked at the time of loss or damage? Yes    No
If yes, please enclose claim check
Has formal claim been filed against the carrier? Yes    No
If yes, has payment been made to you? Yes    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
PLACE
 
DATE
   
 

Claims not falling in the above mentioned sections

 
Type of claim:
 
Incidence of claim description:
Place of loss
 
Date of loss
 
Claimed amount
Claim Number:
 
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
   
 

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)
Insured’s Name as per Bank Account
Bank Account Number
 
Branch Name
 
IFSC Code
Email address
Attachments Cancelled Cheque    Bank Passbook Copy
In Support of Bank Details
(Please tick the type of proof submitted)
*Physical copy of cancelled cheque with payee name printed is required. If name of payee is not printed on the cheque please attach copy of the first page of bank passbook
 
 
 
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.
 
 
 
 
Date: