This accident insurance claim form helps an employee or their family submit a claim under the company's group personal accident (GPA) policy for accidental death, permanent or temporary disability, or medical expenses where covered. It gathers accident facts, witnesses and documents for HR to forward; the insurer's own claim form must also be completed.
This form supports HR in filing the claim. The insurer's official claim form must also be completed and signed by the insured or claimant.
1. Insured Employee
Employee Name
Employee ID
Designation
Department
Date of Birth
2. Claimant (if not the employee)
Claimant Name
Relationship to Employee
Nominee as per records: Yes / No
Mobile Number
Address
3. Accident Details
Date and Time of Accident
Place of Accident
On Duty / Off Duty / Commuting
How the Accident Happened
Nature of Injuries
Police Informed: Yes / No, FIR No. and Police Station
Workplace Incident Report No. (if on duty)
4. Witnesses
Name
Address
Mobile
[Witness Name]
[Address]
[Mobile]
[Witness Name]
[Address]
[Mobile]
5. Benefit Claimed
Accidental death
Permanent total disability
Permanent partial disability
Temporary total disability, absent from [DD/MM/YYYY] to [DD/MM/YYYY]
Accidental medical expenses (if covered)
6. Documents Enclosed
Insurer claim form
Medical records and treating doctor's certificate
Disability certificate (for disability claims)
FIR / police report (where applicable)
Death certificate and post-mortem report (for death claims)
Claimant ID proof and cancelled cheque
Declaration
I declare that the facts stated are true and complete to the best of my knowledge, and I authorise [Company Name] to forward this claim and documents to the insurer and to obtain any further information required.
Benefit claimed: death, permanent total, permanent partial or temporary total disability
Accident narrative with date, time and place
Police intimation or FIR details where applicable
Witness details
Medical treatment and disability certificate fields
Claimant bank details and relationship if the claimant is a nominee
When to use it
An employee suffers an accidental injury, on or off duty, covered under GPA
A family member claims the death benefit after an employee's accidental death
An employee is unable to work for weeks after an accident and the policy pays weekly benefit
HR needs to record a road or workplace accident for insurance and safety purposes
How to customise this template
1Insert your GPA policy number, insurer and benefit table
2Add the workplace incident report link for on-duty accidents
3List the insurer's document requirements for each benefit type
4Include an HR contact for bereaved families
HR tips
Intimate the insurer as soon as possible; accident claims are time-sensitive
Be compassionate and proactive when supporting a family after a death
Collect certified copies of police and post-mortem records where required
For on-duty accidents, also follow your ESI or employee compensation process
Accidents may also trigger ESI, employee compensation and police reporting obligations. Use this as a starting point and review with your insurer and legal adviser.
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Frequently asked questions
What does group personal accident insurance cover?+
Typically accidental death and permanent or temporary disability, and sometimes medical expenses, as listed in the policy schedule. It may cover accidents off duty as well.
What documents are needed for an accidental death claim?+
Usually the insurer's claim form, death certificate, FIR and post-mortem report where applicable, nominee ID and bank details. The insurer confirms the final list.
Who can file a GPA claim after an employee's death?+
The nominee or legal heir files the claim, usually with HR's support as the policyholder.
Important: This form helps HR process your claim. The insurer's or TPA's official claim form must also be completed, signed and attached where required.
Note: This internal form helps HR support your claim. The hospital's pre-authorisation request and the insurer's or TPA's claim form must also be completed where required.
Employee and Patient
Employee Name
Employee ID
Mobile Number
Patient Name
Relationship
E-card / Member ID
Admission Details
Admission Type: Planned / Emergency
Hospital Name and City
Network Hospital: Yes / No
Treating Doctor
Diagnosis / Proposed Procedure
Date of Admission
Expected Length of Stay (days)
Room Category Opted
Room Rent Eligibility as per Policy: ₹[Amount] per day