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INJURED DETAILS TO BE FILED BY CLAIMANT
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* Indicates required question
CASE NUMBER
*
Your answer
NAME OF DECEASED
*
Your answer
FATHER/HUSBAND NAME
Your answer
DATE OF ACCIDENT
*
Your answer
PLACE OF ACCIDENT
Your answer
DATE OF BIRTH OF DECEASED
*
Your answer
MARITAL STATUS
(M FOR MARRIED & S FOR SINGLE)
Choose
M
S
NO OF DEPENDENTS
*
Your answer
MONTHLY INCOME OF DECEASED
*
Your answer
FUTURE PROSPECTS
(PERMANENT JOB/SELF EMPLOYED)
*
Choose
PERMANENT JOB
SELF EMPLOYED/FIXED SALARY
INSURANCE COMPANY NAME
Your answer
ADVOCATE NAME
Your answer
NAME OF CLAIMANT
*
Your answer
ACCOUNT NUMBER OF CLAIMANT
*
Your answer
IFSC CODE
*
Your answer
MOBILE NUMBER OF CLAIMANT
*
Your answer
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