Motor Insurance Claim Form

Raheja QBE General Insurance co Ltd

1800-102-7723 / customercare@rahejaqbe.com / Website - http://www.rahejaqbe.com
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

As soon as Loss or Damage has become known we should be notified without delay. If any details are unavailable, they may be sent later after submission of this form.
A. The claim form is to be duly filled and signed by the insured. B. Please fill this form in Block Letters and Tick the Boxes where appropriate and do not leave any column
unanswered.
Policy Number Vehicle Number Claim Number

Class of Vehicle: 1. Private Car 2. Commercial 3. Two-wheeler

Insured Details

Insured/Claimant Name
Address
City Pin code State
Mobile No : Office/Residence:
Email ID:
NEFT Details:
Bank Name: Bank Branch:
State: City:
MICR Code: IFSC Code:
Payee Name: Payee Account Number:
UPI /Wallet ID:

Loss Details:

Date &Time of Accident D D M M Y Y Y Y H H S S AM / PM

Place of Accident Type of Loss: Own Damage Theft Third Party

Short Description of Accident

Driver Details at the time of Accident:

Name: Age
Occupation: Contact No:
Driving License, No: Name of RTO:

Relationship of Driver: Self Paid Driver Friends Relatives

Co passenger details: No of occupants at the time of accident:
Applicable for Commercial Vehicle
Permit No: GR/LR No:
Permit Valid Up to: Permit Valid for:
Fitness Issue date: Fitness Valid Up to:
Applicable for third party property damage or injury
Police report Lodged: Yes, No If Yes FIR NO Name of Police Station
Name of Third Party/Occupants/Driver/Property Contact No Type of Injury/Property damage Name of Hospital where admitted Any Legal/Court Notice Received

I hereby declare having submitted the following documents :

Copy of Policy Copy of RC Book Copy of Driving license Estimate of Repairs Copy of Fitness Certificate Copy of Permit

Copy of FIR G. R. Form

DECLARATION: I/We hereby declare that the details given above are true and correct to the best of my belief and knowledge. In event above information or any part thereof is found incorrect,
I/We agree that all rights under the policy will be forfeited .I/We also agree to provide additional information to the company ,if required.

Date D D M M Y Y Y Y
Insured Signature
 For Accident Claims For Theft Claims

• Proof of insurance - Policy copy • Original Policy document

• Copy of Registration Book, Tax Receipt [Please furnish original • Original Registration Book/Certificate and Tax Payment Receipt.
for verification] • All the sets of keys/Service Booklet/Warranty Card/Original
• Copy of Motor Driving License of the person driving the vehicle Purchase Invoice.
at the time of accident (Please furnish original for verification) • Police Panchnama/ FIR.
• Police Panchnama /FIR ( In case of Third Party property damage • Police Final Investigation Report/Non-Traceable Report.
/Death / Body Injury). • Acknowledged copy of letter addressed to RTO intimating theft
• Estimate for repairs from the repairer where the vehicle is to be and informing "NON-USE"
repaired • Form 28, 29 and 30 signed by the insured and Form 35 signed by
• Repair Bills/Invoices and payment receipts after the job is the Financer, as the case may be, undated and blank
completed. • Letter of Subrogation.
• NEFT details of insured along with Cancelled cheque / Bank • Letter of Indemnity.
Passbook. • Consent towards agreed claim settlement value from yourself and
Financer
• NOC from the Financier if claim is to be settled in your favor.

NEFT Documents

Bank Statement or Passbook copy

AML / KYC Documents

Pan card copy KYC documents as per AML/KYC rules

The list given is indicative in nature. Further additional documents may be called for depending on the nature of the claim.

DISCHARGE VOUCHER:

Claim No._ I/We hereby acknowledge having received a sum of Rs. /-

Rupees (_ ) from Raheja QBE General Insurance Company Ltd,

towards full and final settlement of my/our claim upon the said company under Policy No._ in respect of the

damage caused to my/our Vehicle No. in an accident that occurred on / /_ (DD/MM/YYYY)

Place Signature Date

Name of Insured/Claimant

Raheja QBE General Insurance Company Limited, CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141.

Registered Office - 5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai – 400059, Website - http://www.rahejaqbe.com, Service mail ID -
customercare@rahejaqbe.com , Contact No.- 022-41715050, Toll free No. 1800-102-7723.

Trade logo displayed belongs to R Raheja Investments Pvt. Ltd. & QBE Insurance Group Ltd. and used by Raheja QBE General Insurance Company Limited under License. For
more details on risk factors, terms and conditions, please read the sales brochure/policy wording before concluding a sale.