General Insurance

CLAIM INTIMATION DETAILS

Date of Incident *

Time of Incident *

Location of Incident *

Please select the policy benefits that you and/or passenger(s) intend to claim *

Personal accident – Death

Personal accident – Permanent partial disability / Permanent total disability

Emergency medical expenses for injury (in-patient)

Emergency evacuation

Daily allowance incase of hospitalization due to injury

Missed flight connection

OPD treatment due to injury

Trip Pick Up Location *

Trip Drop Location *

Uber Registered Account Holder's & Claimant Details

Uber Registered Account Holder's Name *

Account Holder's Mobile Number *

Account Holder's Email *

Claim intimation for *

Number of claimants intend to file a claim* *

ATTACHMENTS

Max File size: 5 MB/attachment

Uber Trip Status *

I/we herewith understand that Reliance General Insurance Co limited (RGICL) reserves the right to process the claim as per the policy terms and conditions of the policy.

I/we hereby declare that the information furnished is true and correct to the best of my knowledge and belief, In Addition to the above I/we also consent RGICL, to seek necessary medical information / documents from the hospital / Medical Practitioner who has attended on the person against whom this claim is made.

In addition to the above I also declare that RGICL will reserve the rights to seek all the original documents in physical form for a period of one year from the date of claim submission and also will be refunding the entire claim amount to RGICL if any misrepresentation/concealment of facts are been noted in my respective hospitalization related to claim/ hospitalization

reliancegeneral.co.in I 022 4890 3009 (Paid)
IRDAI Registration No. 103. Reliance General Insurance Company Limited. Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express Highway, Goregaon (East), Mumbai - 400 063. Corporate Identity Number: U66603MH2000PLC128300. GROUP PERSONAL ACCIDENT, UIN: RELPAGP01001V010001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.