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 Indusind General Insurance Co limited (IGICL) 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 IGICL, 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 IGICL 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 IGICL if any misrepresentation/concealment of facts are been noted in my respective hospitalization related to claim/ hospitalization