Fillable Printable Motor Insurance Policy Claim Form
Fillable Printable Motor Insurance Policy Claim Form
Motor Insurance Policy Claim Form
MOTOR INSURANCE POLICY
Claim Form
1. Name as per Policy
2. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
3. Contact Details Phone No. Mobile
E-mail Id
4. Limits of Indemnity under
the Policy/IDV (Rs.)
S U R N A M E M I D D L E N A M E F I R S T N A M E
Version 1.1, April 2011
Policy No.
Period of Insurance From To
Claim No.
D D M M Y Y Y Y
If any detail or information Is not readily available please do not delay the dispatch of this form and such particulars may be sent later.
1
D D M M Y Y Y Y
A. DETAILS OF INSURED/CLAIMANT
1. Date of Loss Time of Loss
2.
Loss Location
Address
3.
Contact Details of person/s at Loss Location
Name
Relationship with Insured
Contact Details
4. Describe cause of
Loss/Damage (Sketch the
accident using diagram on
Page 4 of the form)
5. Estimated Loss (Rs.)
: A.M. / P.M.
Plot No/Door No. Building Name
Road Area
City Pincode
State
Phone No. Mobile
E-mail Id
B. DETAILS OF LOSS/ACCIDENT
D D M M Y Y Y Y
SBI General Insurance Company Ltd.
2
1. Registration No. Make
2. Model Chassis No.
3. Engine No. VIN No.
4. Date of Registration RTO Jurisdiction
5. Date of Transfer RTO Jurisdiction
6. Type of Fuel Colour of Vehicle
7. Vehicle Class Two Wheeler Pvt. Car Commercial Miscellaneous
Others (specify)
C. VEHICLE DETAILS
D D M M Y Y Y Y
D D M M Y Y Y Y
WITNESS DETAILS
1. Were there any witnesses to the loss/accident? Yes No
If 'Yes',
2. Name as Person/s
3. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
4. Contact Details Phone No. Mobile
E-mail Id
INFORMATION TO AUTHORITY
1. Has the loss been reported to an Authority? Yes No
If 'No', reason for not reporting
If 'Yes', provide details Fire Police Municipality Other
2. Name of Authority
3. Information Report No./ Date
Authority Reference No.
4. Contact Person/s
5. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
6. Contact Details Phone No. Mobile
E-mail Id
S U R N A M E M I D D L E N A M E F I R S T N A M E
S U R N A M E M I D D L E N A M E F I R S T N A M E
D D M M Y Y Y Y
3
1. Is the Insured the Sole Owner of the property? Yes No
If 'No', specify
Nature of Interest
Person/s who has/have
interest on property
Address
Contact Details
Plot No/Door No. Building Name
Road Area
City Pincode
State
Phone No. Mobile
E-mail Id
E. DETAILS OF OTHER INTEREST
1. Name of Driver
2. Relationship with Insured
3. Date of Birth Gender M F
4. Address
5. Contact Details
Plot No/Door No. Building Name
Road Area
City Pincode
State
Phone No. Mobile
E-mail Id
6. Driving License No. Issuing RTO
7. Date of Issue Date of Expiry
8. Type of License Permanent Temporary
9. Class M-Cycle W/G M-Cycle Wo/G LMV Transport Non-Transport HGV
Passenger Goods
10. Special Endorsements, if any
F. DRIVER DETAILS
D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
1. Is the loss / damage covered under any other Insurance? Yes No
If 'Yes', specify details and attach a copy of the policy
Name of Insurer
Address
Contact Details
Policy Number Sum Insured
Period of Insurance From To
Plot No/Door No. Building Name
Road Area
City Pincode
State
Phone No. Mobile
E-mail Id
D D M M Y Y Y Y D D M M Y Y Y Y
D. DETAILS OF OTHER INSURANCE
1.
Name
2. Name of Contact Person
3. Address
4. Contact Details
Plot No/Door No. Building Name
Road Area
City Pincode
State
Phone No. Mobile
E-mail Id
H. GARAGE/BODYSHOP/REPAIRER DETAILS
I. THIRD PARTY DEATH / INJURY / PERSONAL ACCIDENT DETAILS (Attach additional sheet, if required)
Sl. Name of Whether Address Contact No. Death/Type Name of
No. person TP of Injury Hospital where Attending Legal/Court
Passenger admitted Doctor Notice received
Name of Details of any
J. DIAGRAM (Mark the damage with an X in the diagram given below)
4
1.
Speed at the time of accident
Kmph
2. Type of Loss Own Damage Theft Partial Theft Others (specify)
Third Party Death Third Party Injury Third Party Property Damage Personal Accident
3. Purpose for which the vehicle
was being used at the time
of accident/theft
4.
No. of people travelling in the
vehicle at the time of accident
5. Weighment Details RLW ULW GVW Weight Carried
6. In case of theft, keys in the possession of
Name
Contact No.
G. ACCIDENT/THEFT DETAILS
Left View
Top View
Right View
Do you wish to provide any other information? Yes No
If 'Yes', specify
L. DETAILS OF OTHER INFORMATION
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 I/we agree
that if I/We have made, or in any further declaration, the Company may require in respect of the said accident, shall make any false or fraudulent statement,
or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and void, and all rights to recover there under in
respect of past or future loss/accidents shall be forfeited.
I/We have received a list of documents with this claim Form and have understood the entire requirement to be fulfilled for administration of this claim and the
Company shall not be held responsible for any delay in settlement of claim due to non-fulfilment of requirements including the documents as mentioned in
the claim form.
I/We agree to provide additional information and additional documentation to the Company, if required.
Place Signature of Proposer
Date: Name of Insured/Claimant
D D M M Y Y Y Y
DECLARATION
LIST OF DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT*
5
For Accident/Theft Claims
1. Proof of insurance - Policy / Cover note copy
2. Copy of Registration Book, Tax Receipt [Please furnish original for
verification]
3. Copy of Motor Driving License of the person driving the vehicle at the
time of accident (Please furnish original for verification)
4. Police Panchanama /FIR ( In case of Third Party property damage
/Death / Body Injury)
5. Estimate for repairs from the repairer where the vehicle is to be
repaired
6. Repair Bills/Invoices and payment receipts after the job is completed
Additional Documents for Theft Claims
1. Original Policy document
2. Original Registration Book/Certificate and Tax Payment Receipt
3. All the sets of keys/Service Booklet/Warranty Card/Original Purchase
Invoice.
4. Police Panchanama/ FIR and Final Investigation Report /
Non Traceable Report.
5. Acknowledged copy of letter addressed to RTO intimating theft and
informing "NON-USE"
6. Form 28, 29 and 30 signed by the insured and Form 35 signed by
the Financer, as the case may be, undated and blank
7. Letter of Subrogation
8. Consent towards agreed claim settlement value from yourself and
Financer
9. NOC from the Financer if claim is to be settled in your favour.
* Additional documents required by us if any, will be intimated to you as and when required
DISCHARGE VOUCHER
Claim No.
I/We hereby acknowledge having received a sum of Rs. ___________________/- Rupees (_________________________________________________________)
from SBI General Insurance Company Ltd. towards full and final settlement of my/our claim upon the said company under Policy No._____________________
in respect of the damage caused to my/our Vehicle No. in an accident that occurred on ______/_____/__________ (DD/MM/YYYY)
Place Signature of Proposer
Date: Name of Insured/Claimant
D D M M Y Y Y Y
Tear here Tear here
Losses during the 3 preceding years
Date of Loss Claim Description and Cause of Loss Value of Loss (Rs.) Insurer
K. DETAILS OF PREVIOUS LOSSES
