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CLAIM INTIMATION FORM

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					                                                                                Annexure-I

                               CLAIM INTIMATION LETTER

To

               The Director,
               __________________________________
               __________________________________
               __________________________________


Sub: -         INTIMATION      OF   LOSS   UNDER     GROUP      PERSONAL        ACCIDENT
               INSURANCE SCHEME FOR GOVERNMENT EMPLOYEES.
Sir,
               It is to intimate you that Sh. …………………………………………………………..…………..
S/o Sh. ………………………………………………………………. R/o ……………………………………………………….
Working as …………………..………………………………………….. in …………………………………………………..
posted    at   ……………………………………….………………..           has   died/lost   following   body   parts
…………………………………………………….. Suffered permanent total disability/permanent partial
disability due to accident of ………………………………………………………………………………….. on dated
…………………………………………………… You are requested to register the claim at the earliest in
favour of insured undr the captioned scheme.


Thanking You


(_____________________)
SIGNATURE
(Not in case of death)
                                                               Countersigned by
                                                         Head of the Office/Department

Documents to be submitted in event of claim:
     1) Claim intimation immediately after knowledge of occurrence.
     2) Claim form along with:-
           i)     Copy of FIR
           ii)    Post Mortem report in the event of death/death certificate from
                  competent authority.
           iii)   Treatment/disability certificate in the event of Permanent
                  Disability/Permanent Partial Disability.

NOTE: -              ALL DOCUMENTS SHOULD BE DULY ATTESTED BY HOD.
                                                                          ANNEXURE-II
                                     CLAIM FORM

1. NAME OF INSURED:  __________________________________________________
   DESIGNATION:      __________________________________________________
   PARENTAGE:        __________________________________________________
   RESIDENTIAL ADDRESS:____________________________________________
                     __________________________________________________
                     __________________________________________________
   POSTED AT         __________________________________________________
   DEPARTMENT        __________________________________________________
   PREMIUM PAID ON   __________________________________________________

2. AGE               _________________________ SEX _____________________
   DATE OF ACCIDENT  __________________TIME OF ACCIDENT ________________
   HOW DID ACCIDENT OCCUR _____________________________________________
   WITNESS OF ACCIDENT ______________________ HIS NAME __________________
   ADDRESS           __________________________________________________
                     __________________________________________________
                     __________________________________________________

3. NATURE OF INJURY RECEIVED ___________________________________________
   NATURE OF DISABLEMENT ______________________________________________
   NAME & ADDRESS OF HOSPITAL __________________________________________
   PRESENT STATUS OF INJURY/HEALTH _____________________________________

4. DETAIL OF POLICY REPORT LODGED
   WITH FIR NO AND DATE     _____________________________________________
   ULTIMATE LOSS            _________________________((loss of body parts, PTD)
   DETAIL OF BODY PARTS LOST ____________________________________________
   DETAIL OF PERMANENT TOTAL DISABILITY _________________________________
   POSTMORTEM/TREATMENT TAKEN FROM ___________________________________

5. I hereby declare that the foregoing statements are true to the best of my knowledge
   and belief and I have not attempted to conceal any relevant pertinent information. In
   case of any false/fraudulent /untrue averment whatsoever the policy said policy
   shall be void ab-inito and my right/my claim for compensation will be forteited.


(_______________________)
SIGNATURE
(Not in case of death)
                                                             (                  )
Dated:                                                  Countersigned by Head of the
Place:                                                       Office/Department



   FOLLOWING DOCUMENTS ENCLOSED IN SUPPORT OF THIS CLAIM
   1. FIR
   2. POST MORTEM REPORT
   3. BRIEF ACCIDENT REPORT BY THE DEPARTMENT
   4. ANY OTHER DOCUMENT

				
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