GOOD SAMARITAN SCHEME FORM
Personal Details Of Patient
Full Name
Mobile Number
Date and Time of Accident
Accident Place/Road
Hospital Details
Referred Hospital
Hospital Reach Date and Time
Vehicle Details
Vehicle Type
Ambulance
Private Vehicle
Vehicle Number
Bystander Details
Bystander Name
Contact Number
Address
Other Details
Aadhaar Card Number
Bank Details
Select Bank
State Bank of India
HDFC Bank
ICICI Bank
Axis Bank
Kotak Mahindra Bank
IndusInd Bank
Yes Bank
Punjab National Bank
Bank of Baroda
Canara Bank
Union Bank of India
Bank of India
Indian Bank
Central Bank of India
IDBI Bank
UCO Bank
Indian Overseas Bank
Bank of Maharashtra
Punjab & Sind Bank
Federal Bank
South Indian Bank
RBL Bank
Karnataka Bank
Dhanlaxmi Bank
Karur Vysya Bank
City Union Bank
Tamilnad Mercantile Bank
DCB Bank
Jammu & Kashmir Bank
Saraswat Bank
Suryoday Small Finance Bank
Ujjivan Small Finance Bank
Equitas Small Finance Bank
AU Small Finance Bank
ESAF Small Finance Bank
Fincare Small Finance Bank
Jana Small Finance Bank
North East Small Finance Bank
Shivalik Small Finance Bank
Utkarsh Small Finance Bank
Branch
IFSC Code
Injury Details
Injury Type
Major Injury
Brain Injury
Spine Injury
Upload Documents and Photos
Accident Photo
Aadhaar Card Photo
Bank Passbook Photo
MLC Proof (Police FIR Statement)
Hospital Statement Proof
Bystanderd Address Proof
Submit Form