Motor Claim Form

Policy No. / Cover Note No.:

Period of Insurance:

1. Name of the Insured & Address, e-mail ID & Mobile No.

Name:

Address:

PIN:

e-mail ID:

Mobile No.:

PAN No.:

Bank A/c. Particulars:

2. DETAILS OF ACCIDENT / THEFT:

Date:

Time:

Place:

FIR No. & Date:

Charges u/s:

Police Station:

In case other Vehicle(s) is/are involved/ responsible, specify vehicle No(s).:

Policy details of that Vehicle(s):

For what purpose was the vehicle being used at the material time?

Brief particulars of the accident:

FIR: Specify the reasons for delayed FIR or not lodging an FIR:

3. Details of other Insurance Policy, if any:

Policy No.:

Period of Insurance:

4. THE INSURED VEHICLE PARTICULARS

Regd. No.:

Make:

Year:

Engine No.:

Chasis No.:

Cubic / Carrying Capacity:

5. For Private Vehicle:

Whether Occupant(s) / Pillion - Rider(s) was / were carried at the material time of accident? ---Select--- Yes No

Give name and addresses, contact Tel. No. of passengers/other witnesses if any:

For Commercial Vehicle:

Regd. Laden Weight: kg

Unladen Weight: kg

Weight of Goods Carried: kg

Type of Permit:

Nature of Goods carried:

Person Carried in Goods Vehicle:

Whether Public Liability Policy is taken (For dangerous / Hazardous Goods)? ---Select--- Yes No

If yes, specify Policy No. & validity period:

No. of Passengers carried in case of PSV at the material time of accident:

No. of Passengers permitted under Permit:

Whether the vehicle attached with Trailer(s)? ---Select--- Yes No

If Yes, specify No(s).:

Policy / Cover note Nos.:

Period of insurance:

6. DETAILS OF INJURY / DEATH TO THIRD PARTY / EMPLOYEES / DAMAGE TO THIRD PARTY PROPERTY ETC.:

Specify No. of Persons Injured / Died:

Injured:

Death:

Whether any of your Workman sustained injury / death: ---Select--- Yes No

Injured:

Death:

Specify the wages paid to the concerned Workman/men:

Specify the nature of damage to TPPD:

7. DETAILS OF THE DRIVER ON THE WHEEL, AT THE MATERIAL TIME OF ACCIDENT:

Name & Address of the Driver:

Age:

Relationship with Insured: Put 'X' Mark:

Driving Licence No.:

Issuing Authority:

Specify, type(s) of Motor Vehicle(s) Authorised to drive:

Date of expiry:

Specify, Original issuing Authority and subsequent renewing Authorities in chronological order:

Whether the Driving Licence is / was suspended any time by the Competent Authority / Court: ---Select--- Yes No

If yes, give details:

Has the driver had any previous accidents in the five years, if yes give details:

8. DETAILS OF DAMAGE TO INSURED VEHICLE:

When & where the damaged vehicle can be inspected:

Nature & Description of the Damage to the insured Vehicle:

IDV : Rs..

Approximate Estimated Cost of repairs: Rs.

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