SBI General Insurance Company Limited

IRDA Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546

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1800 22 1111 | 1800 102 1111
www.sbigeneral.in
GROUP PERSONAL ACCIDENT INSURANCE POLICY
Claim Form (For SBI & its Associate Bank Account Holders Only)
Issuance of this form does not amount to admission of any liability or a waiver of any of the terms and conditions of the insurance contract. If any claim is in any
manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices, whether by the Insured Person/Claimant or anyone acting on
behalf of the Insured Person, then the benefits under this policy shall be void and all benefits payable under it shall be forfeited.

Policy No. Claim No.

Period of Insurance From D D M M Y Y Y Y To D D M M Y Y Y Y

A. DETAILS OF INSURED/CLAIMANT

S U R N A M E M I D D L E N A M E F I R S T N A M E
1. Name of the Claimant

2. Name of the Insured S U R N A M E M I D D L E N A M E F I R S T N A M E

3. Relationship with Insured Designation (if applicable)

4. Date of Birth of Insured D D M M Y Y Y Y Gender Male Female

5. Address Plot No/Door No. Building Name

Road Area

City District

State Pincode

6. Contact Details Phone No. Mobile

E-mail Id

B. DETAILS OF ACCIDENT/INCIDENCE

1. Date of Accident/Incidence D D M M Y Y Y Y Time of Loss : A.M. / P.M.

2. Cause of Accident/Incidence

3. Details of Accident/Incidence

4. Accident/Incidence
Location Address

Pincode

5. Were there any witness to the Accident/Incidence? Yes No

If ‘Yes’, provide details,
Name of Witness

Address of Witness

Pincode

Contact Details Phone No. Mobile

E-mail Id
Version 1.6, Aug 2014

6. Is Witness relative of Claimant? Yes No

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Corporate & Registered Office: ‘Natraj’, 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai - 400 069.
 C. INFORMATION TO POLICE AUTHORITY

1. Has the loss been reported to Police Authority? Yes No

If 'No', reason for not reporting

First Information Report No. Medico Legal Case (MLC) No.

Report Date D D M M Y Y Y Y

Address of Police Station

Pincode

Contact Details Phone No. Mobile

E-mail Id

2. Was the person moved to hospital immediately after the accident? Yes No
If ‘Yes’,
3. Name of Hospital

Address of Hospital

Pincode

Contact Details Phone No. Mobile

E-mail Id

4. Date of Admission D D M M Y Y Y Y Date of Discharge D D M M Y Y Y Y

D. DETAILS OF OTHER INSURANCE/INTEREST

1. Is the Accident/Incidence covered under any other Insurance? Yes No

If 'Yes', specify details and attach a copy of the policy

Name of Insurer Policy No.

Policy Issuance Office Location Sum Insured (Rs.)

Period of insurance From D D M M Y Y Y Y To D D M M Y Y Y Y

E. FOR WHICH BENEFIT DO YOU CLAIM? [PLEASE TICK (P

) THE APPROPRIATE BOX]

Benefit Amount Claimed

Accidental Death

F. PAYEE DETAILS [Payable to Nominee (*All fields are mandatory)]

Bank Name Bank Branch

Bank Account No. IFSC Code

MICR No. PAN No.

Note: It is agreed that the Policyholder/Claimant will intimate in writing to SBI General about any change in bank account details. Please attach a cancelled cheque
pertaining to the same account. In case premium is issued from the same bank account through cheque, the cancelled cheque is not required.

G. ANY OTHER INFORMATION YOU MAY WISH TO PROVIDE

I/We, the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect; and I/We agree that if
I/We have made, or make in any further declaration that the Company may require in respect of the said accident or any false or fraudulent statement, or any
suppression or concealment, my/our claim shall be absolutely forfeited.
I/We hereby extend my/our consent to the Company for sharing my/our personal data with State Bank Group entities for specific purpose of availing services offered
by State Bank Group(please strike this clause in case you do not wish to disclose the personal data).

Place Signature of Insured/Claimant

Date D D M M Y Y Y Y Name of Insured/Claimant
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 H. ENCLOSURES CHECKLIST

Accidental Death:

Claim Form duly signed and attested by respective authorised Original Certificate of Insurance
SBI or its Associate Bank's official

Copy of Death Certificate attested by issuing authorities Copy of Final Police Report attested by issuing authorities

Copy of FIR / MLC Copy / Spot Panchnama / Inquest Panchnama Affidavit from the legal heirs of the deceased
attested by issuing authorities (in case nomination has not been filed by deceased)

Copy of Post Mortem Report attested by issuing authorities Cancelled Cheque of Nominee

Note: The Company reserves the right to seek additional documents (including KYC documents) and information as and when necessary for processing of
the Claim.

I. STATE BANK OF INDIA & ITS ASSOCIATE BANKS AUTHENTICATION

This is to certify that Mr / Ms ___________________________________________________________ having account number _____________________________

in __________________________________________ Branch, Branch Code ______________________ is / was covered under Group Personal Accident Master

Policy No. ___________________________________, Certificate No. _________________________________ for Sum Insured Rs._________________________.

Nominee details which are provided above are valid as per our records. Yes No Not Applicable

The above information is true to best of my knowledge and we agree to provide any further information that may be required.

Place: Signature of Authorized Personnel:

Date: D D M M Y Y Y Y Name of Authorized Personnel:

Bank Branch Seal:

ANNEXURE I: TO BE COMPLETED BY NOMINEE IN THE EVENT OF INSURED’S DEATH

1. Name of Nominee S U R N A M E M I D D L E N A M E F I R S T N A M E

2. Relationship with Insured Date of Birth D D M M Y Y Y Y

3. Address

Pincode

4. Contact Details Phone No. Mobile

E-mail Id

If nominee is minor, kindly provide the Legal Guardian details

5. Name of Guardian S U R N A M E M I D D L E N A M E F I R S T N A M E

6. Relationship with Insured Date of Birth D D M M Y Y Y Y

7. Address

Pincode

8. Contact Details Phone No. Mobile

E-mail Id

I/We hereby declare and warrant the truth of the foregoing particulars in every respect. I /We agree that if I/We have made or shall make false or untrue
statement, suppression or concealment, my/our right to compensation shall be forfeited.
I/We also hereby declare that I am/we are accepting the amount in full discharge of your obligations under the policy to the Insured Person and /or his/her
legal heirs. I/we will hold you indemnified in the event of any claim under this policy being made against you by any other person or persons.

Place Signature

Date D D M M Y Y Y Y Name of Nominee

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 ANNEXURE II: MEDICAL CERTIFICATE - TO BE FILLED BY TREATING DOCTOR

1. Name & Address S U R N A M E M I D D L E N A M E F I R S T N A M E

of the Insured

2. Gender Male Female Date of Birth / Age D D M M Y Y Y Y /

3. Nature of the
Accident/Incident and
details of injuries sustained

4. Cause of Accident/Incident

5. Is death: a) Solely due to Accident/Incident Yes No

b) Traceable to any disease Yes No

If 'Yes', give details

c) Traceable to any previous injury Yes No

If 'Yes', give details

6. Was insured under influence of drugs / intoxicants / alcohol at the time of accident? Yes No

7. Was the insured suffering from any disease or injury which may have contributed to the accident Yes No
or likely to aggravate his/her condition?

If 'Yes', give details

I certify that I have examined the above named Insured, the above statements are correct and that the injured person is necessarily disabled by the accident
referred to

Name of treating Doctor

Qualifications Registration No.

Address

Contact Details Phone No.

E-mail Id

Signature of the Doctor Date D D M M Y Y Y Y

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