Bharti AXA General

Insurance Company Limited

844-691-8883 - Canada
 844-691-8885 - USA
+91 11 47324403 - India

[email protected]
 www.bharti-axagi.co.in

SmartTraveller Insurance Policy - Claim Form

PART I

Important Note
The issue of this form is not to be taken as an admissibility of liability. Please fill this form in Block Letters and Tick the Boxes appropriate and do not leave any
column unanswered. If any detail or information is not readily available, please do not delay despatch of this report and such particulars may be sent later.

Policy No. SX40052807

Claim Number:
where
Period of Y Y Y
Insurance:08/08/2020D D Y Y Y to 05/11/2020D D M
M Y

1 Insured Details (To be filled in block letters)

Name of the Insured MR.IMTIHAZUDDIN ABDULGAFUR SHAIKH

Permanent 1,PARK AVENUE,CHITRAKUT SOCY,RAJNAGAR CHAR RASTA,NR.N.I.D,PALDI380007

Address in India

,AHMEDABAD- City
Pincode :380007 State GUJARAT

Date of Departure D Date 08/08/2020M Flight No. AI2 1102 From AHMEDABAD To DELHI
of Departure
Flight No.AI 127 From DELHI To CHICAGO
D

Passport No. P013412 Date of Birth 28/09/1956D22222 M M Y Y Y Y Gender: Male Female

22228/09/1956D
Contact Nos. Mobile No. Office +91
Residence +91 Email ID

2 Claim Details
Type of Claim: Hospitalization Medical Expenses Dental Treatment Personal Accident Liability (Personal / Legal)
Repatriation Loss of Passport Baggage Home Contents Pet Care
Trip Delay / Cancellation Financial Emergency Others

3 Hospitalization / Medical & Dental Treatment / Personal Accident / Repatriation

(Please note: The attending physician’s report in Part II along with discharge summary & FIR (in case of injury) are essential for claim under this section)

Patient / Claimant Details:

Name

Date of Birth D D
M M Y Y Y Gender: Male Female Relationship with the Insured
Y
Date of Admission D D
M M Y Y Y Y Date of Discharge D D M M Y Y Y Y
Name of Hospital where admitted / treated

Address of Hospital

Name of attending Doctor / Physician

Name and address of your family Physician

Illness / Disease:
Nature of Disease / Illness / Diagnosis
Date first noticed / symptoms of Disease / Illness DD M M Y Y Y Y
Have you ever been treated for this Illness / Disease before Yes No If yes, provide details

Registered office address: Bharti AXA General Insurance Co. Ltd.

First Floor, Ferns Icon, Survey No. 28, Doddanekundi, Bangalore - 560 037. IRDA Reg. No. 139. ST
Registration No.: AADCB2008DST001 Co. Registration No.: U66030KA2007PLC043362
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Injury:
Date of Injury / Accident: D D M M Y Y Y Y
Brief narration of Accident

Whether Police report filed?

Yes No If yes, attach a copy of the report
Police station & Report No.
If no, please state reasons for not informing Police
Are you on any kind of medication prior to Illness / Disease / Injury in question Yes No
If yes, provide details
Previous claims history under any other existing or expired Travel, Health or Personal Accident Insurances

Nature of disesase / Date of Claim Amount

Sl. No. Name & Address of Insurance Company Policy No.
illness / injury Claim Ref. No. Claimed

Amount of claim (Please mention & include under what head claims are lodged viz. hospitalization, medical, dental treatment etc. and attach
separate sheet, if the space is insufficient)
Sl. No. Description Bill No. Date Amount in Foreign Currency

Total Amount claimed in INR

Emergency Evacuation Services Availed Yes No If yes, furnish details

Compassionate visit done by any Family member

Yes No If yes, name of the visiting person
Relationship with the Insured Date of Travel D D
M M Y Y Y Y
4 Loss Of Passport / Emergency Financial Assistance
(Please note: The intimation to Police authority & copy of report is essential for claim under this section)
Passport No. Date of Loss D D
M M Y Y Y

Y
Brief description of loss

Details of Police Report Report No. Date D D

(Please attach copy) M M Y Y Name of Police Station
Y
Y
Details of Expenses Incurred Date Place Amount

5 Delay / Loss of Checked in Baggage

(Please note: The intimation to Airlines, Copy of their PIR & Baggage Tag is essential for claim under this section)

Scheduled Date & Time of Arrival D D

M M Y Y at Hrs at Airport
Y
Y
Actual Date & Time of Arrival of Baggage D D
M M Y Y at Hrs at Airport
Y
Y
Brief description of loss
Name of the Airlines
Airlines Ref. No. Date & Time when loss was intimated to Airlines
Provide the Carrier / Airline details of having given any payment or declined the claim

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 In case of delay of baggage provide details of emergency purchases made & in case of loss, please provide details of items lost
Sl. No. Details of Items Lost / Emergency Purchases made Qty. Date of Purchase Purchase Price

Please attach the credit card statement and / or receipts showing emergency purchases made & the correspondence with the airlines.

6 Trip Delay / Cancellation / Hijack / Missed Connection / Overbooked Flight or

Emergency Accommodation (Please note: The documentary evidences regarding delay / cancellation etc. is mandatory for claim under this section)
Flight Details
Scheduled Date & Time of Departure DD
M M Y Y Y at Hrs.
Actual Date & Time of Departure DD Y
M M Y at Hrs.
Y Y
Y
Reason for the Delay / Cancellation of the Trip
Details of Financial Losses / Additional Expenses due to Delay / Cancellation of Trip or Emergency Accommodation
Sl. No. Description Amount

Was the Accommodation / Boarding / any kind of Compensation provided by Carrier / Airlines If
Yes No
yes, please provide the details
7 Home Contents / Fire / Burglary / Pet Care
Date of Loss D D M M Y Y Y Y
Brief description of Loss

Details of Loss (Please attach relevant supporting documents)

Sl. No. Description Amount

8 Liability (Personal / Legal) or Any other type of Claim

(Please note: The documentary evidences regarding accident / police report / legal reports etc. are mandatory for claim under this section)
Date of Accident D D M M Y Y Y Y
Brief description of Accident

Details of Liability / Status of Legal Case

9 Other Insurance Details
Are you currently insured under any other Travel, Health, Home or Baggage Insurance policies? Yes No If yes, provide details

Sl. No. Name & Address of Insurance Company Policy No. From To Sum Insured (Rs.)

Do you wish to provide any other information as relevant to the claim made? a Yes No If yes, details (if required you may attach
separate sheet)
10 Consent for Access to Records & Declaration
I/We hereby authorize Bharti AXA General Insurance Co. Ltd. or any other individual/agency engaged by Bharti AXA to obtain all medical or legal record pertaining to the above patient/insured
available with any hospital/doctor/legal forum.
I/We agree to provide additional information to the Company, if required. I/We the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statement
in every respect, and if I/We have made, or in any further declaration the Company may require in respect of the said accident, shall make any false or fraudulent statement, or any suppression or
concealment, the policy shall be void and all rights to recover there under in respect of past or future claims shall be forfeited.
Data Privacy Notice:
I/We hereby provide consent to the Company for collecting/retaining any information relating to Me/Us including Sensitive Personal Information (“hereinafter cumulatively referred to as
“INFORMATION”), that is either available with the Company or disclosed by Me/Us while obtaining the policy of Insurance from the company or otherwise. I/We further understand that the
Company may use the INFORMATION for servicing the Insurance policy obtained by Me/Us and for same may share the INFORMATION with any reinsurer, insurance association, medical
authorities, other Insurers, statutory authorities, court, governmental body, regulator etc., or with services provider(s) engaged by the Company for servicing the Insurance policy, underwriting the
risk, settlement of claim etc. without obtaining our specific consent for such sharing and we hereby provide our consent to Company for same.
I/We understand that whenever I/We would like to update/correct the INFORMATION, we will intimate the Company for the same, so as to enable the Company to amend/correct the
INFORMATION accordingly. Further in the event I/We would like to withdraw My/Our consent provided herein, I/We would intimate the Company of the same in writing and also understand that,
in the event of such withdrawal by Me/Us, the Company reserves the right to not provide Me/Us the Services for which it has sought the INFORMATION.

Date DD
Signature of the Insured
M M Y Y Y Y Place
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PART II
Attending Physician’s Statement

Name of the Patient

Age in Years Gender: Male Female

Address

City
Pincode State

Illness / Disease Cases

Date when patient approached for first consultation / treatment D D
M M Y Y Y

Y
Diagnosis

Please provide previous Medical history of the Patient

Is the present condition attributed to congenital defect? If yes, please provide details

Injury Cases
Nature of the accident & details of injuries sustained

Are the injuries solely due to the accident or traceable to any previous injuries / disease / infirmities?

Nature of treatment / surgery performed for present illness / disease / injury

Has the injury resulted in to any Permanent Total / Partial Disablement? Yes No
If yes, please provide details

Was the patient under the influence of intoxicants or drugs at the time of the accident? Yes No
If yes, please provide details of diagnosis done

Are you patient’s usual Medical Attendant? Yes No

If yes, please give details of previous treatments for any illness / disease / injury

Doctor’s Name Doctor’s Name & Address Stamp

Registration No.
Addresss

Telephone No.
Signature of the Doctor
Date DD Y Y
M M Y Y

CLAIM FORM/TRAVEL/THINQ/08-15. Insurance is the subject matter of solicitation.

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