Fillable Printable Motor Insurance Claim Form

Motor Insurance Claim Form

a. The claim form is to be duly filled and signed by the insured.

b. All facts and statements must be factual not influenced or biased in any favor.

c. The damaged vehicle must be parked at safe place to avoid any subsequent loss/Theft

Policy Number

Claim Number

Vehicle Number

Insured Details

Please fill in your current correspondence address. Where you want us to send letters/communication for this claim

Name

Address

City Pin

Mobile Landline

Email ID

Loss Details

Date & Time of accident _____ am/pm

D D M M Y Y

Place of accident

Type of Loss

Own Damage Theft *Third Party

Short Description of

Accident

Police Report Details, If any

___________________________________________________________________

Driver details at the time of accident

Name Age

Driving License No. Name of RTO

Learners License □ Yes □ No

Co passenger

details

*Please fill the details overleaf for third party damage.

Declaration

I/We hereby declare that the details given above are true and correct to the best of my belief and knowledge. In the event

above information or any part thereof is found incorrect, I agree that all right under the policy will be forfeited.

I also declare that there was/ was no third party bodily injury or property damage involve in accident.

Date Signature of Insured

Motor Insurance Claim Form

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILIT Y

Corporate Office Address:

001 Trade Plaza, 414 Veer Savarkar Marg, Prabhadevi, Dadar West, Mumbai 400025

Telephone: 40976666

Applicable for commercial vehicle:

No. of Passenger carried at the time of

accident G R Number & Date

Permit No Permit Issuing Authority

Permit Valid up to Permit valid for (Area)

Applicable for third party property damage or injury

Name of Third

Party/Occupants

/Driver

Contact No

Fitness Granting Authority Fitness valid up to

Type of Injury Name of the Hospital

where admitted

Any Legal/

Court Notice

Received

I hereby declare having submitted the following documents:

Copy of Policy/Cover Note Copy of Fitness Certificate

Copy of RC Book Copy of Permit

Copy of Driving License Copy of FIR

Estimate of Repairs G.R Form

DECLARATION

I/We here by declare that the details given above are true and correct to the best of my belief and

knowledge .In event above information or nay part thereof is found incorrect, I agree that all rights

under the policy will be fortified. I/We also agree to provide additional information to the company,

if required.

Date Signature of Insured

Corporate Office Address:

001 Trade Plaza, 414 Veer Savarkar Marg, Prabhadevi, Dadar West, Mumbai 400025

Telephone: 40976666