Professional Documents
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Motor Claim Form
Motor Claim Form
1. Important Instructions
a. The issuance of this form is not to be taken as an admission of liability. b. To be signed by the Insured(Registered Owner) of the vehicle, or where Insured(Registered Owner) is a Partnership or Corporate Body, by an authorized signatory of such Partnership or Corporate Body along with the office seal of the concerned organization. c. Please do not leave any column unanswered. d. All facts and Statements must be factual not influenced or biased in any form. e. The damaged vehicle must be parked at safe place to avoid any subsequent damage/loss. The Company will not be responsible for the same. f. Please read carefully the attached list of documents required for faster processing of your claim. g. All documents provided by the Insured must be Self Attested.
Date(dd/mm/yy) :____________________Time (a.m./p.m.) :___________________Speed (km/hr)_________________________ Exact Place Where incident occurred : _________________________________________________________________________ Place to which the vehicle was heading for before incident :_________________________________________________________ Purpose for which vehicle was being used/parked at the time of incident: ______________________________________________ Nature & Weight of goods carried at the time of incident (Comm. Veh): _______________________________________________ No of people travelling at time of incident :_________________________ Is it reported to the Police ? YES / NO
Name & Address of the Police Station :______________________________________________________________________ Gen. Diary/Crime No/FIR No and Date.:_____________________________________________________________________ Name and Address of the place where Insured vehicle is parked: ___________________________________________________ Estimated Loss Amount (Rs.) :_____________________________________________________________________________
4. Details of Vehicle
Registration No :_________________________Make : __________________________Model:_____________________________ Date of 1st Registration : ________________________________Date of Transfer (if applicable) :___________________________ Name of Financier (if any):_______________________________________ Colour of Vehicle :__________________________ Type of Fuel :_____________________________Chassis No.: _______________________Engine No.: ___________________
5. Details of Driver
Name :__________________________________ _______Relation with Insured : ______________________________________ Address :_________________________________________________________________________________________________ Contact Number :_______________________Gender : Male / Female Driving License No :____________________________
Issuing RTO :____________________________ _________ License Expiry Date :______________________________________ Class : MCycle / LMV / HGV / Transport / Non-Transport Type : Permanent / Learners
Injury/Death Details:
Name Address Phone No. In What Capacity Nature of Injury
7b.
____________________________________________________________________________________________________
8. Other Insurance
Detail of other insurance policies indemnifying you or the driver in respect of above accident:
Undertaking
1. 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/We have made any false or fraudulent statement or there be any suppression or concealment of facts, the claim shall be forfeited. 2. I/We have received a list of documents with this claim Form and will provide such complete documents along with the signed Claim Form and have understood all the requirement to be fulfilled for administration of this claim. The Company shall not be held responsible for any delay in settlement of claim due to nonfulfillment of requirements including the submission of documents as required. 3. I/We agree to provide any additional information/documents to the Company, if and when required. 4. I/We hereby understand, agree and submit that No Claim Bonus (NCB) allowed to me/us under the Policy for which the Claim is being preferred/lodged is subject to the fact that the own damage claim experience for the insured vehicle or my/our earlier insured vehicle (in case of transfer of No Claim Bonus from earlier insured vehicle) in previous year policy(s) was NIL. Accordingly I/We once again submit/undertake that the No Claim Bonus (NCB) allowed under the current year Policy for the Insured Vehicle for which the Claim is preferred is based on the above NIL Claim history. Further I/We undertake and submit that in case the basis of availing the No Claim Bonus (NCB) under the current policy is incorrect, then the company may at its discretion impose suitable damages on the preferred claim which may include forfeiture of all benefits on own damage section of policy.
Mandate Form for Electronic Transfer of Claim Payments Insured Name: Vehicle Registration No: Bank Details Bank Name Bank Branch Account Type IFSC Code* MICR Code* Account Number Bank Address *Please also attach one Blank Cancelled Cheque for NEFT/RTGS Payment Insured Name: Date & Place: (Signature/Thumb impression of Insured)