MOTOR CLAIM FORM

1. Date & Time of Accident/Loss
3-A) For Private Vehicle
3-B) For Commercial Vehicle
NCB GAP PIR
Claim Serial no:
NO
YES
NO
YES
Spot Survey ?
Claim:
____________________________________(Date of Intimation)
MOTOR VEHICLE CLAIM-FORM
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS ADMISSION OF ANY LIABILITY
** Please answer all required questions fully
Policy:
From _________________ to _________________
1.) Name of Insured, Address, E-Mail & Mobile No. Reporting BO, DO or CLAIM-HUB
__________________________________________________
__________________________________________________
__________________________________________________
2.) DETAILS OF ACCIDENT / THEFT
AM / PM
Place
(Exact)
In case other vehicle(s) is/are involved/ responsible, specify vehicle No(s): ___________________________________________
FIR No.: ____________ Dt.: ______________ Police St.: ______________________ Charges u/s: ________________
Name of the Complainant, who lodged the FIR: ________________________________________________________________
Specify the reason if any, of delayed FIR or not lodging an FIR: ___________________________________________________
3.) THE INSURED VEHICLE PARTICULARS
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Regd. No: Make: ____________________ Year: ________
Chassis No: ____________________
Whether Occupant (s) / Pillion Rider(s) was / were
carried at the material time of accident ? Yes / No
Give name & address, Contact Ph. No. of passengers / others or
witnesses if any ______________________________________
Indemnifying without prejudice...!!
4.) Details of other Insurance policy, if Any?
Mail:
RC Particulars ?
Rc
Permit Type:
Regd. Laden Wt.:__________________ Unladen Wt.: __________________ Carried Wt.: __________________
Nature of goods carried: _____________________________________________ No. of Carried Persons.:
No. of passengers carried in case of PSV at the material time of accident/loss. : ____________ Road Tax till:
Fitness till:
Permit Valid? NO
YES
Details of load challan.:______________________________________________________________________________
Whether public liability policy is taken for dangerous/hazardous goods. : Yes / No , If yes specify: ______________________________
Whether the vehicle attached with Trailer (s) ? . : Yes / No If yes specify : __________________________________________________
Brief particulars of the accident/loss:
Engine No: _______________ CC _________ Carrying Capacity____
Regd. & Head Off: 24 ”Whites Road”, Chennai -1600014 (TN)
UNITED INDIA INSURANCE COMPANY LIMITED

2. 5.) DETAILS OF INJURY/DEATH TO III-PARTY/EMPLOYEE/DAMAGE TO IIIrd PARTY PROPERTY Etc.:
Specify No. of Persons Injured / died: Injured Nos Death Nos
Whether any of your workman sustained injury / death. Injured Nos Death Nos
Specify the wages paid to the concerned Workman / men : __________________________________________
Specify, Nature of TPPD damage: Approx cost:
N.B.: Kindly enclose a separate sheet stating details of name, age, income etcof the person(s) injured / died. ___________________
6.) DRIVER DETAILS AT THE THE TIME OF ACCIDENT ON THE WHEEL:
Name: _______________________________________________
Add: ___ ______________________________________________
___________________ _____________________________
Owner driver (Self)?
Own Paid Driver ?
Relative/Friend/Other?
Driving Licence No.:
Issuing Authority: ___________________________________
Authorised to drive, Type(s) : __________________________
Date of Issue: ____________________
Validity (NT): ____________________
Validity (TR): ____________________
Date of Birth: ____________________
Specify, Original issuing authority & subsequent renewing authorities in chronological order, if any?:
Whether the driving licence is /was suspended any time
by the Competent Authority / Court ? If yes, give details:
2. 3 .
Has the driver had any previous accidents in the five years ? if yes give details: _____________________________
7.) DETAILS OF DAMAGE TO INSURED VEHICLE.:
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 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 of fact, the policy shall be void and all right to recover
thereunder, in respect of past, present or further accidents shall be forfeited.
Place:
Date: Signature of Insured
** Only the insured can sign the claim-form.
Nature & description of the damages to the insured Vehicle:
When & where the damaged vehicle can be inspected?
Add: __________________________________________
Adviser Name: ________________________________
Is workshop 'Authorised' ? YES NO
Is workshop 'Cashless' ? YES NO
N. B.: Please enclose the estimated Cost of repairs of the insured vehicle.
ESTIMATE (Approx): Rs
1 .
Indemnifying without prejudice...!!.
DL Particulars ?
8.) DECLARATION.:
Accidental / Others _____________________
IDV: (Rs.) __________________
__________________________________________________
Rc

3. NCB GAP PI
Indemnifying without prejudice...!!.
Date & Time of Accident/Loss AM / PM
IDV
6. Loss
Detail:
1. Name of Insured: ______________________________________________________
2. Correspondence add.: _________________________________________________
__
_______________________________________________
______________________________________
3. Policy No: _____________________________________
4. Period of Insurance: _____________________ to _________________________
5. Vehicle Regd No:
Place (Exact)
7. Description of loss/damages: __________________________________________
______________________________________________________________________________
______________________________________________________________________________
8. Estimate of Loss: ______________________
10. Whether TPPI/TPPD is involved with brief details of
injuries and/or property damages of IIIrd party: ______________________________
9. Workshop details: ______________________________________________________
Rs
Place:
Date:
Signature
Name..............................................................
Mandatory
** Please fill the required columns fully .
Intimation No. Office Code.
INTIMATION-DETAILS
For office use only
Rc
Rc
MOTOR-CLAIM INTIMATION LETTER
Regd. & Head Off: 24 ”Whites Road”, Chennai -1600014 (TN)
UNITED INDIA INSURANCE COMPANY LIMITED

4. Received from UNITED INDIA INSURANCE COMPANY LTD. the sum of
Rs.______________________ ( In words __________________________________________)
in full payment of our bill number ___________________ dated ______________
for repairs done to the vehicle reg. number _________________________
belonging to the hereunder countersigned whose 'Satisfaction Voucher'
duly signed is also appended.
I/We hereby acknowledge having received from UNITED INDIA INSURANCE
COMPANY LTD. for my/our Vehicle registration number ______________________
which has been repaired to my/our full satisfaction, and I We admit that the payment of
Rs____________________ ( In words _________________________________________)
made by UNITED INDIA INSURANCE COMPANY LTD. for such repairs is in the full
discharge of my/our claim upon the said company under policy number _______________
in respect of the damages caused to the said vehicle in an accident occured on the
________ day of ____________ 202__.
Place:
Date:
Signature of Insured
Name..............................................................
Rs
Rs 1/-
STAMP
above
5000/-
Rs.______________________
Insured's counter Signature Repairer's Signature
Indemnifying without prejudice...!!. Rc
Regd. & Head Off: 24 ”Whites Road”, Chennai -1600014 (TN)
UNITED INDIA INSURANCE COMPANY LIMITED
DISCHARGE VOUCHER
SATISFACTION VOUCHER