MOTOR CLAIM FORM
Policy No.
Period of Insurance


SUBMISSION OF THIS FORM DOES NOT BIND COMPANY FOR LIABILITY
Please duly fill all relevant questions.

1. INSURED
a. Name
. Address for correspondence
c. Telephone
  Email
2.INSURED VEHICLE
Make & Year  
Engine No.  
Chassis No.  
Registration No.  
A a) Was vehicle in proper working condition?
  b) For what purpose was vehicle being at time of accident?
  c) Was trailer attached?
  d) If motor cycle/ scooter:  
    1. Was side-car attached?
    2. Was pillion rider carried?
B. ADDITIONAL INFORMATION (FOR COMMERCIAL VEHICLE ONLY)
          Following question need be answered in case of commercial vehicle only:
a) Registered laden weight.  
b) Unladen weight.  
c) Weight of goods carried.  
d) Nature of permit.  
e) Nature of goods carried.  
f) Was vehicle for hire?  
g) If lorry/ jeep/ tractor, was trailer attached?  
h) Number of passengers carried.  
i) Number of passengers permitted.  
3. DRIVER AT TIME OF ACCIDENT
a) Name:  
b) Age:  
c) Address:  
d) Is driver    
  1. Owner
  2. Paid driver
  3. Owner's relative or friend
       
e) If paid driver, how long has been in your employment?  
f) Was he under influence of intoxicating liquor or drugs?  
g) Driving license number:  
h) Issuing authority:  
i) Was license temporary/ permanent  
j) Date of expiry:  
k) Details of endorsement/ suspension, if any:  
l) Has he been involved in any accident before?  
m) Has he been charged by Police? If so, why?  
5.DETAILS OF ACCIDENT
a) Date and time:  
b) Place:  
c) Speed of your vehicle at time of accident:  
d) Give short description of accident:  
e) If any third party was responsible for accident, give name and address:  
6.DAMAGE TO INSURED VEHICLE
a) Full details of damage:  
b) Estimated cost of repairs:  
c) When and where can damaged vehicle be inspected?  
7. THIRD PARTY INJURY/ PROPERTY DAMAGE
a) Name:  
b) Address:  
c) Full detail of personal injury sustained:  
d) Name and address to injured person  
e) Full details of property damaged:  
f) Has notice of any claim been given to you?  
g) Insurance details of third party if any  
8.INJURY TO DRIVER/ OCCUPANT
a) Was driver/ any occupant injured?  
b) If yes, give full details:  
9.WITNESS
a) Give names and addresses of passenger/other witness if any  
b) Did police constable take particulars of accident?  
c) Was accident reported to police? If not why?  
d) If yes, to which police station?  
e) Application entry no. and date( FIR diary no.)  
10.THEFT
a) Date and Time:
b) Place:
c) What was stolen?
d) Estimated cost of replacement:
e) By whom discovered and reported to Police?
f) Has theft been reported to Police?
g) When?
h) Which police station?
i) Application entry no. and date( FIR diary no.)
I/We above named, do hereby to best of my/our knowledge and belief, warrant truth of foregoing statement 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 said accident, shall make my false or fraudulent statement, or any suppression or concealment, Policy shall be void and all rights to recover thereunder in respect of past or future accidents shall be forfeited.
Place:
Date: