Cover Note / Policy No :

Period of Insurance :

Date of Accident :

Name :

Address :

City :

Pin Code :

Contact Person :

Contact Number :

Date & Time of Occurrence :

Brief description of the Occurrence :

When did you first come to know of the accident? :

When the claim was first notified to the Insurer? :

Approximate value of loss :

FIR done or not : ---Select--- Yes No