Go Digit General Insurance Ltd.
DIGIT PAYMENT PROTECTION POLICY
CLAIM FORM
UIN: IRDAN158CP0092V01202021
[Link] form should be filled in by the Policyholder or an authorized Representative and must be signed and dated in
all applicable sections.
2. The issue or acceptance of this form by the Company, must not be construed as an admission of any liability on the
Company, nor a waiver of any of the terms and conditions of the insurance contract.
3. Claim form must be filled online or manually or using voice record at Call Centre.
4. Please answer all questions completely. In case of insufficient space, please attach an additional sheet.
5. Please attach all Original bills & receipts pertaining to your claim.
Claim No: _________________________
INSURED DETAILS
1) Insured Name:______________________________________________________________________________________________
2) Address: __________________________________________________________________________________________________
____________________________________________________________________________________ PIN CODE____________
3) a) Mobile No____________________________3 b) Email Id ________________________________________________________
4) Policy No:_________________________________________________________________________________________________
POLICYHOLDER/INSURED/ THIRD PARTY BANK NEFT DETAILS FOR CLAIM PAYMENT
I hereby declare that below bank details are correct and should be used to process all payment due in relation to my
insurance policy.
1) Name on Bank Account: _________________________________________________________________________________________
2) Bank Name: _________________________ Account Number ______________________________ Branch ________________________
3) Account Type: Saving/Current 4) IFSC Code: _____________________________ 5) MICR Code_________________________________
6) PAN Number: _________________________________________
DETAILS OF LOSS
a. Please name the section/ sections under which you are
claiming.
b. Date, exact time and location of the loss or damage?
c. Date and exact time of discovering the loss or damage?
(if applicable)
d. Date & time of loss or damage been reported to bank by
claimant
e. Claimant details such as Name of Account holder
f. Account number onto which unauthorized transaction
occurred.
g. Mobile & email ID of Account holder
h. Registered address of Account holder
i. Please give details of the card / account/ wallet on
which unauthorized / fraudulent transaction happened.
(if applicable)
j. Date & time of blocking the card/account/ wallet on
which unauthorized/fraudulent transaction happened
k. Please give full details and description of how the loss
or damage occur?
l. In the event of loss, which Police Station has been
notified? (if applicable)
Attach a copy of FIR/ Police report.
m. Was the loss incidence reported to Card Issuer/
Financial Institution / Relevant Authority?
If yes, attach a copy of the report submitted
n. Was there any recovery in the loss occurred?
If Yes, please provide details.
o. Any Additional information relevant to claims
p. Estimated Loss Amount (in INR)
DETAILS OF OTHER INSURANCE AND PREVIOUS LOSS
a. Is the accident / incidence covered under any other Insurance?
If Yes, please provide the following information:
i. Name of Insurer
ii. Address
iii. Phone No. and Email
iv. Policy No.
Digit Payment Protection Policy – Claim Form Page 1 of 2
Go Digit General Insurance Ltd.
v. Period of insurance
b. Have you incurred any claim before?
If Yes, please provide the details
DECLARATION
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 agree that if I have made any false or fraudulent statement or there be any suppression or concealment, no claim shall
be payable resulting into forfeiture of premium and/or cancellation of policy.
I/We have received a list of documents with this claim Form and have understood all the requirements to be fulfilled for administration
of this claim.
I/We agree to provide additional information to the Company, if required.
I/We hereby do give consent that payment of claim amount be made to third person as per the bank details mentioned above
Name: Signature of Insured/ Claimant:
Date:
Go Digit General Insurance Ltd, A Company incorporated under Indian Companies Act, 2013 and licensed by Insurance Regulatory
and Development Authority of India [IRDAI] vide Reg No. 158, Corporate Identification Number U66010PN2016PLC167410, Reg.
Address Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru 560095. Website: [Link]
CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDAI)
1. Please submit clear and legible copy of one document (valid and effective as on date of claim submission) each from
Part A and Part B and your recent passport size photograph (not more than 6 months old) in case claim amount exceeds
Rs 100,000.
a. Photograph
b. Part A (Identity proof, Anyone of below)
i. PAN Card (If PAN Card is not available please submit any of the documents mentioned below)
ii. Passport
iii. Voter’s Identity Card
iv. Driving License
v. Personal Identification and Certification of the employees for your identity
vi. Aadhar (Letter issued by Unique Identification Authority of India containing details of name
address and Aadhar Number)
vii. Job Card issued by NREGA duly signed by an officer of the State Government
c. Part B (Address proof, Anyone of below)
i. Electricity Bill not older than 6 months from the date of Insurance Contract
ii. Telephone Bill pertaining to any kind of telephone connection like mobile, landline, wireless etc,
provided it is not older than 6 months from the date of claim submission
iii. Ration Card
iv. Valid lease agreement along with rent receipts which is not more than 3 months old as a residence
proof
v. Saving Bank Passbook with details of permanent/ present residence address (updated up to 1
month prior to claim sub-mission document)
vi. Statement of saving bank account with details of present/ present address (updated up to 1 month
prior to claim submission document)
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