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Motor OD Claim Form: United India Insurance Company Limited

This document is a motor vehicle insurance claim form from United India Insurance Company requesting details about a policyholder, their vehicle, and information regarding an accident or theft in order to process an insurance claim. The form collects information such as the policy and insured details, vehicle details, date and location of loss, driver details, accident or theft description, workshop and repair estimates, police report, and third party losses or injuries. The policyholder must declare that the information provided is true to the best of their knowledge in order to submit the claim for processing.

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Ritu Rani
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3K views1 page

Motor OD Claim Form: United India Insurance Company Limited

This document is a motor vehicle insurance claim form from United India Insurance Company requesting details about a policyholder, their vehicle, and information regarding an accident or theft in order to process an insurance claim. The form collects information such as the policy and insured details, vehicle details, date and location of loss, driver details, accident or theft description, workshop and repair estimates, police report, and third party losses or injuries. The policyholder must declare that the information provided is true to the best of their knowledge in order to submit the claim for processing.

Uploaded by

Ritu Rani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNITED INDIA INSURANCE COMPANY LIMITED

Registered & Head Office, 24 - Whites Road, Chennai - 600 014.


Motor OD Claim Form
The issue of this form is not to be taken as Admission of Liability

Policy No.
InsuredDetails: Insured Name :
Insured Address:

Pin Code: State:


Mobile: E-Mail:
Aadhar No: PAN No:
Bank Account Account No: Bank Name:
Details: IFSC Code No: Branch Name:
Vehicle Details: Registration No: Make: Model:
Engine No. Chassis No.
Date & Place of Date of Loss: Time: A.M. / P.M.
Loss: Place of Accident / Theft:

Driver details: Driver Name:


Driving Licence No / Expiry Date:
Accident Details :
Provide brief
description

No of Occupants carried:
Workshop Details: Name & Address of Workshop:

Workshop Mobile: Email: Estimate Amount: Rs.


Theft Claim: Theft of Vehicle: Yes / No Details :

Theft of Accessories: Yes / No Details :

FIR Details: Accident/Theft reported to police: Yes/No Name of Police Station:


Date of reporting to Police: FIR/Crime diary number:
Third Party Loss Any Injury/Death to Driver: Yes/No Details:
Details
Any TP Injury/Death: Yes/No Details:

Any Injury/Death to Occupant: Yes/No Details:

Any TP Property Damage: Yes/No Details:

DECLARATION BY THE INSURED


I/We 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 I / We agree that 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 the policy shall be void and all
rights to recover thereunderin respect of past or future accidents shall be forfeited.
Date:
Place: Signature of Insured / Claimant

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