CLAIMS NOTIFICATION - PERSONAL ACCIDENT - SAGITARIES INSURANCE SERVICES

Submit your personal accident claim information online

At SAGITARIES INSURANCE / FPG, we’ve made it very easy for you to submit your personal accident claim online. Simply complete the following form and attach the relevant documents. We will then review your claim and if needed, a personal accident claim representative will contact you directly to confirm your claim details and request any additional information.

Basic Documents for Personal Accident Claim

Download: SAGITARIES Personal Accident Form to be filled and signed by attending physician)
Police / Investigation Report
Medical Certificate
Hospital Statement of Account/Charge slips (Original copy)
Original Official Receipts of hospital bills/professional fees
Original Official Receipts of medicines purchased outside the hospital and their prescriptions.
Original Copy of Death Certificate
Proof of Beneficiary's identity like Birth Certificate, Marriage Certificate
Others (i.e. autopsy report, medico-legal report, pictures, newspaper clippings)

Need help with your claim? Call 0915-265-1203 / 0915-496-7047 or you can e-mail sagitariesinsuranceservices@gmail.com

POLICY HOLDER

POLICY NUMBER*

OCCUPATION*

NAME*

PRIVATE ADDRESS*

AGE*

BUSINESS ADDRESS*

ACCIDENT

DATE OF ACCIDENT*

DATE OF ACCIDENT

STATE PRECISELY HOW THE ACCIDENT OCCURED*

TIME OF ACCIDENT*

NATURE & EXTENT OF INJURIES*

PLACE OF ACCIDENT*

NAME AND ADDRESS OF WITNESS(IF ANY)

DISABILITY

STATE THE NUMBER OF DAYS YOU HAVE BEEN ENTIRELY  CONFINED TO YOUR BED, ROOM OR HOUSE BY THE DIRECTION OF YOUR MEDICAL ATTENDANT, CONFINED TO MY BED FOR NUMBER OF DAYS

FROM(MM-DDD-YYYY  HH:MM) & TO(MM-DDD-YYYY  HH:MM)

CONFINED TO MY ROOM FOR NUMBER OF DAYS

FROM(MM-DDD-YYYY  HH:MM) & TO(MM-DDD-YYYY  HH:MM)

CONFINED TO MY HOUSE FOR NUMBER OF DAYS

FROM(MM-DDD-YYYY  HH:MM) & TO(MM-DDD-YYYY  HH:MM)

STATE THE EXTENT AND DURATION OF YOUR INABILITY TO ATTEND TO YOUR BUSINESS OR OCCUPATION, I HAVE BEEN DISABLED TOTALLY FOR NUMBER OF DAYS

FROM(MM-DDD-YYYY  HH:MM)  & TO(MM-DDD-YYYY  HH:MM)

I HAVE BEEN DISABLED PARTIALLY FOR NUMBER OF DAYS

FROM(MM-DDD-YYYY  HH:MM) & TO(MM-DDD-YYYY  HH:MM)

I AM NOW _______ DISABLED*

IF STILL DISABLED, HOW MUCH LONGER THE DISABILITY IS LIKELY TO CONTINUE

I RESUME WORKING ON(MM-DDD-YYYY  HH:MM)

IF NOT YET WORKING, STATE APPROXIMATE DATE WHEN YOU EXPECT TO DO SO(MM-DDD-YYYY  HH:MM)

GIVE THE NAME AND ADDRESS OF THE MEDICAL PRACTITIONER WHO IS, OR HAS BEEN ATTENDING TO YOU FOR THIS INJURY

HAS HE OR ANY OTHER PRACTITIONER ATTENDED TO YOU PREVIOUSLY FOR ANY ILLNESS OR INJURY?*

IF SO, GIVE PARTICULARS

ARE YOU ENTITLED TO CLAIM COMPENSATION FOR ACCIDENT INJURY FROM ANY OTHER COMPANY/COMAPANIES?*

IF SO, GIVE PARTICULARS

DO YOU WISH TO SUBMIT ANY PROPOSITION FOR AN IMMEDIATE SETTLEMENT

UPLOAD DOCUMENTS

PERSONAL ACCIDENT FORM B

POLICE REPORT/INVESTIGATION REPORT

MEDICAL CERTIFICATE

HOSPITAL STATEMENT OF ACCOUNT/CHARGE SLIPS

ORIGINAL OFFICIAL RECEIPTS OF HOSPITAL BILLS/PROFESSIONAL FEES

ORIGINAL OFFICIAL RECEIPTS OF MEDICINES PURCHASED OUTSIDE THE HOSPITAL AND THEIR PRESCRIPTIONS

ORIGINAL COPY OF DEATH CERTIFICATE

PROOF OF BENEFICIARY'S IDENTITY LIKE BIRTH CERTIFICATE, MARRIAGE CONTRACT(ORIGINAL)

OTHERS(I.E AUTOPSY REPORT, MEDICO-LEGAL REPORT, PICTURES, NEWSPAPER CLIPPINGS)

DECLARATION

I HEREBY DECLARE, THAT I HAVE RECEIVED THE INJURIES ABOVE DESCRIBED BY VIOLENT, ACCIDENTAL, EXTERNAL AND VISIBLE MEANS AND I CLAIM COMPENSATION UNDER THE ABOVE POLICY IN RESPECT THEREOF. I HEREBY WARRANT THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT I HAVE NOT WITHHELD FROM THE COMPANY ANY MATERIALS INFORMATION IN CONNECTION WITH THIS CLAIM.