B. DETAILS OF ACCIDENT:
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1 (A joint venture between of State Bank of India and Insurance Australia Group) Registered Office: Corporate Centre, State Bank Bhavan, Madame Cama Road, Mumbai CLAIM FORM - WORKMENS COMPENSATION ISSUE OF THIS CLAIM FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY Policy Number Period of Insurance to Claim Number A. DETAILS OF INSURED/CLAIMANT: Name of the Insured : Address City State Pin Code Phone Number : Mobile Number ID Business/Occupation Period of Insurance From / / to / / Limits of Indemnity under the policy B. DETAILS OF ACCIDENT: Date of Accident / / Time of Accident A.M. / P.M. Cause of Accident / Incidence : Address line 1 : Address line 2: City State Pin Code Phone Number : Mobile Number ID WITNESS DETAILS Were there any witnesses to the Accident and resultant injuries/death? (Yes) (No), If Yes, Name of Person/s Address City State Pin Code Phone Number Mobile Number INFORMATION TO AUTHORITY Has the Accident been reported to an Authority (Yes) (No), Name of Authority Authority Reference No. Contact Person/s Address City State Pin Code Phone Number Mobile Number SBI General Insurance Co. Ltd. WC Claim Form 1
2 ID ID C. DETAILS OF OTHER INSURANCE/INTEREST Is the Accident/damage covered under any other Insurance (Yes) (No), If Yes, specify details and attach a copy of the policy Name of Insurer: Address Phone Number MobileNumber ID Policy No. Period of Insurance to Sum Insured (Rs.) SBI General Insurance Co. Ltd. WC Claim Form 2
3 THE INJURED / DECEASED PERSON Name and address of Injured/deceased : Gender: (Male) (Female), Date of birth / Age: Address Phone Number Mobile Number State occupation / nature of work of the injured person Was the Injured/deceased person engaged in this occupation when the accident occurred? If No, state exactly the nature of the work he/she was doing at the time of accident. If the Injured/deceased person in your direct employment? If No, give details Name of the Contractor Address Line 1 Address Line 2 Phone Number Mobile Number Nature of work entrusted to contractor When did the Injured/deceased person enter your service? / / Have the Injured/deceased persons been taken to hospital or medically attended? If Yes, specify (Yes) (No), Name of Hospital / Physician Date of Admission / / Date of Discharge / / Address Line 1 Address Line 2 Phone Number Mobile Number D. INJURY DETAILS State nature of injury & part of body affected Is there disablement? (Yes) (No), If Yes select Total Partial Permanent Temporary Is the disability solely caused by this accident / Incident (Yes) (No), If No, give details How long is the disablement expected to last? Days Upto / / Extent of disability % SBI General Insurance Co. Ltd. WC Claim Form 3
4 Is any improvement possible from current disablement? (Yes) (No), If Yes specify with % improvement and action required Time and date when the injured person actually ceased work. Date / / Time : AM / PM Was the injured person under the influence of alcohol or drugs at the time of accident? (Yes) (No), Present health condition Death examination point of Addiction to drugs / alcohol Disposed to Malinger Any other details Post Mortem Done (Yes) (No), Date of PM Done / / PM No. Name of Hospital where Post mortem has been done 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, the Company may require in respect of the said accident, any false or fraudulent statement, or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and void, and all rights to recover there under in respect of past or future Accident/accident shall be forfeited. Place: Date: Signature: Name of Insured/Claimant: E. INJURY DETAILS The object of the statement is to ascertain the injured person s average monthly earnings. Please therefore observe the following instructions very carefully. Failure to do so will entail unnecessary correspondence and cause undue delay in the settlement of the claim:- 1. If the injured person has been in the service during a continues period (not broken by an absence of 14 or more, then enter the wages paid to him in each month during 12 months immediately preceding the accident. 2. If he has been in the service during a continues period of less than one month, then enter the wages paid to another workmen employed on similar work during 12 months immediately preceding the accident. SBI General Insurance Co. Ltd. WC Claim Form 4
5 3. In all other cases, the monthly wages shall be the average daily earnings (Amount of wages/actual number of days worked) multiplied by 30. F. TABLE OF WAGES Please fill in the table of wages below as applicable to 1, 2 or 3 above. Month and Year Basic pay and dearness Allowance Overtime bonus Concession in value of food stuffs and others All others Total earnings in the period (specify dates) Average monthly wages Were the above stated wages paid, or fallen due for payment, to the injured person? (Yes) (No), Was the injured person absent from work at any time, during the above stated period, for 14 or more consecutive days? (Yes) (No), If Yes, period of absence from / / to / / Reasons for absence The above statement of earnings is accurate to the best of our knowledge and belief. Place: Signature: Date: Name of the Insured: Suggested Documents for Settlement of Claim The following are the some of the elementary documentation required for the processing/determining the liability of the company for claims reported by the Insured. However, please note that the documentation mentioned hereunder is only indicative in nature and further documentation required by the Company will be sought, if required. Basic Documents Required: SBI General Insurance Co. Ltd. WC Claim Form 5
6 General for all type of claims: - Claim Form duly filled in & signed. - Claim Bill. Temporary Disablement Claims: - Medical Certificate regarding Cause & Duration of Disablement. - Medical Bills. Permanent Disablement Claims: - Medical Certificate regarding Disablement. - Memorandum of Agreement as per W.C Act between Insured and the injured workman. Fatal Claims: - - Death certificate. - Copy of post Mortem report. - F.I.R / Final Investigation report? - Form A of W.C Act duly completed by the Insured. - Statement of Witnesses, if any? SBI General Insurance Co. Ltd. WC Claim Form 6
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