UNITED NOIA

UNITED INDIA INSURANCE CO. LTD.

(Subsidiary of General Insurance Corporation of India)

Motor Claim Form

Certificate/Policy No. ***********°******* * ****************

Divisional Office Branch Office (Address) Period of Insurance:. ********* . ************

Date of Accident . **** ******************'*********"

7).
Claim No. . . **********

THE ISSUE OF THIS FORM IS NOT BE TAKEN AS AN ADMISSION OF LIABILITY

PLEASE ANSWER ALL QUESTIONS FULLY
1. aHrara/INSURED

a) Name ***************** *'********* ******************* ' ****°"***********

**°******************************************************

b) Address for correspondence ******** *.

.******************'°°'****'*** '**°*************** *****'******** ******'**********************

********* ********* **** ****.*************************************************

c) Telephone/Mobile No.

2. at4Te5a a/THE INSURED VEHICLE

Engine No.
Registration No. Type of Body Sum Insured
Make &Year

Chassis No.

********°*°**********"****************** *

A) a) Was the vehicle in proper working condotion ? : .**********************************°*°*********************

a ******" *******

) For what purpose was the vehicle being used at the time of accident ?:..
*********** ******

C) Was trailer attached ? ************** ********************************"***"********************

d) If a motor cycle/ scooter.

1.
Was a side-car attached? *************************"*************** *********

2. **************************''

2. Was pillion rider carried ? *"*****°*****************************'** '***************

B) a) Additional Information for commercial vehicle

The following question need be answered in case of Commercial Vehicles only.

a) Registered laden weight

***** **"*****'************************ ************* **************'*********'************.

b) Unladen weight * *** ****************************** * ******

 *************
********* *** ****'***

* * * * * * * *
****** *
c)Weight of goods carried
******** **
*********'****'******
. * * *'*
* **
* .
********'******'.
'*'**'********
'**' **

d) Nature of permit ***'****

*****'****

.
*********** ****
. '*********'***** *****'*******
e) Nature of goods carried
'*** **************.
********** ****

***
*********

c)Was the vehicle plying for hire ? .''******

********************************
'****' ''*******

****
********'******
If Lory/Jeep/Tractor, was a trailer attached to it ?
*****'*

******

h) No. of passengers carried

*******

****
******

i) No. of passengers permitted ***

3. T i a T G AT/DRIVER AT THE TIME OF ACCIDENT

***************"'''

a) Name *******

*********°**°******°**°°**************
***°* **°'******

b) Age . ***********
° * ° * *

**********
.*********************°°******

c) Address .*******. **** *******°'***

Is the driver ?
1. ? ************ ****°

1. Owner? ************ ************

2. a ()? * * * * *

2. Paid Driver? * * * * * * . .
**a***********

e*********

3. Onwer's relative or friends ********.** ** eeoo*.. ****°****°*******.

********* ********°********* ********

If paid driver, how long has

he been in your employement ? **********************.

***°*°*°**°°° ****
* * * * * *

Was he under the influence

of intoxicating liquer or drugs? . e*****°************°°*********** .
°*************"***

) . ********************°***°° ° ****
***********************

g Driving Licence Number and date of issue *********************°****°*.***

*************.
.. *********°**.********'

*******

h) Issuing Authority ***°**************************** . *****************

*********|

i) Date of Expiry **********

********°**°**°****°****
********. ***

Was the Licence temporary /permanent *********°*********.**°*.

********°**°**********. **
*****°*'***°'"***

k) Details of endorsements /suspension, if any '******* *************°°**'**** **

**********
*******'**************°**** * * *****
Has he been involved in any accident before ? *************°***°********** * ***'

m) Has he been charged by the Police ? **********************°**** ***. ****** ***** *****
4. 3 T/OTHER INSURANCE

. *****'*********
Details of other insurance Policylies
indemnifying you in respect of this accident .'*'****** ** ****

5. Juem RT/DETAILS OF ACCIDENT

"*******'**** ** "* ************* *******************************

a) Date and Time
*************'* * . ** *******************'******

*********"******** * **********'*****''*******"

) Place "********* * ***********'*****"

c) Speed of Your Vehicle at the time of accident

*** * *****'******"*******"************"

d) Give a short description of the accident ****'*****'**°**'******'°'*************''*** '****'********'**'.

* ******* ****°*** ***'*************'*

e If any third party was responsible for

the accident, give name and address *************°**°**********'********************** ***°''***

6. TR ad/DAMAGE TO INSURED VEHICLE

) ******************************
* **********'*******************°'***********

a) Full details of damage

.. ******* ************ ******""*******"*****"""****"
) Estimated cost of repairs ****************°****°°°*****°°**°°°************°******************

e****** * **************************************

c When and where can damaged

vehicle be inspected? ******* ************ ************e****************************

7. rR q T M / A/THIRD PARTY INJURY PROPERTY DAMAGE

Name **** ***

b) Address

c) Full details of personal injury sustained °***********°*****************

***************°**°°**°**°°************°****°** *************

d) Name and address of any person / hospital

giving medical attention to injured person
*a********°*°*****************°***°*°°*************************************

Full details of property damaged

***********°**° ******.a*e******** *

Has notice of the claim been given to you

Please furmish details in respect of each person in separate sheet

8. R R FOR afT e/INJURY TODRIVER/ OCCUPANTS

..... * *** ** **** ***********

a Was driver / any occupant injured ? ********************"*********************""********************"

******'**°******'******'***********************"****'*** *****'** ' ' *

b) if yes give full details . **********""****'"******""**************|

******

..... **** ***************"*****""*********"*

C) In what capacity the occupant was travelling.
. * **************** ****************'****************°
9. mftWITNESS
E) unfaai sa enfarat a
a) Give names and address of passengers
*'****'*****'********* *********'*****'***** ''***'*****'******
other witnesses if any ?
***'********** ********** **************

b) Did a police constable take the

''**** '*******'******** *** ****'*****'******'******
particulars of accident

) giet qam gfea ? '*******'*********'****'********'**"******** ***'**** '**** '*****

Was accident reported to police

If not whyy?
***'' ''

*** ***'***
.'***''***' * * * * ' * * * * ' * * * * ' * * * ' * * * ' * * * ' * * * * * * * *

''**'***'***** ********************'*** '***'******'**** ** ***'**** *********

* * *** ****'*''*****'*'****************** ********

d) If yes, which police station
. ** ******************************'****'***** ****' *'***'

CR Diary No
******'**''***********'***"'*** ******

e) . . .

10. t/THEFT
**********************************

'****************'****'****

* * * * * * * * * * * ' * * ' * * * * ' ** ************************************************ *

a) Date and time

**************** *** * * ** ******* ******** ****

b) Place *****'*********'*************'***"''***** '*''***'**'**************

. . i.... ***********"************************"**

c) What was stolen ? .'**'********* '****'''*°*'** *'* '***'"***'°°"*****"****'** *****''******

)
d) Estimated cost of replacement ? * ** ************ *****°**''°*****************"****

. *

e) By whom discovered and reported ? ...

* **** *******************************

Has theft been reported to policee? .'**'***'******'******************'*********'****'°**"***'**"****'****************

g When ******************************************************************************

****** * **************** ****************************

Which police station?

) ************* *********************************** **************

CR Diary No. *****************************************°*************** **** *

wWe the above named do. Hereby, to the best of my our knowledge and belief, warrant the truth of the foregoing
statement in every respect, and We agree, that if We have made or in any further declaration the Company may require
in respect to the said accidents, shall make any false or fraudulent statement or any suppression or co cealment the policy
shall be void and all ight to recover thereunder in respecd of past of further accidents shall be forfeited.

Each Invoice of Workshop / Garage |

Shops should bear the name of United
India Insurance Company Ltd., along with
GSTIN No.- 22AAACU5552C1ZT in case|
a registered claimant wishes to avail the
inputcredit, the invoice should be in
Date
|Insured's name and GSTIN.
Place Signature of the Insured