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CLAIM - FORM - MOTOR Sompo

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168 views2 pages

CLAIM - FORM - MOTOR Sompo

Uploaded by

boschservicebhiwadi
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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Universal Sompo General Insurance Co. Ltd.

(A joint venture between Bank, Sompo Japan Insurance Inc., Indian Overseas Bank, Karnataka Bank and Dabur Investments)
Regd. Office : Andheri (East), Mumbai-4000
MOTOR INSURANCE CLAIM FORM
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
If any detail or information is not readily available please do not delay dispatch of this form and such particulars may be sent later

Claim No. _____________ Policy no. ____________________________ Estimated Loss : Rs. _______________
Vehicle Make_________________ Model_________________ Class of Vehicle : Pvt Car / Two Wheeler / Commercial
Vehicle No. ___________________ Eng No._________________________ Chassis No.__________________

INSURED/CLAIMANT NAME: _____________________________________email:____________________


Address: ___________________________________________________________________________________________
_________________________________________________________________City_______________Pin_____________
Mob ____________________________ Tel Res _________________________ Tel off ____________________________

Time & Date of Accident / Occurrence ____/____/________DD MM YYYY Time am / pm


Place of Accident (location City and State):
Type of Loss OWN DAMAGE THIRD PARTY BODILY INJURY PROPERTY DAMAGE
Purpose for which vehicle was being used : ______________________________________________________________
Name of Garage reported : ___________________________________________________________________________
Address of Garage : _________________________________________________________________________________
Contact Numbers : _________________________________________________________________________________
Short Description of Accident/Incidence (attach separate sheet, if necessary) ____________________________________
__________________________________________________________________________________________________

Police FIR no. (if any) and Police Station____________ ________________________________________

Fire Brigade Location: (in case of fire)_________________________________________________________________


(please provide copies of Police FIR and Fire Brigade Report, if available)

Details of the driver at the subject time of accident


Name _____________________________________________________ Age _____ Occupation_________________
Driver is Owner Paid Driver Relative/ Friend
Driving License No. _________________________________ Badge no ________________________
Effective for (type of vehicle)______________________________Effective upto:______________________________
Please enclose self signed copies of Registration Certificate & Driving License.

To be filled only in case of Commercial Vehicle


Permit validity upto __________________________________Fitness validity upto________________________________
Load carried at the time of accident ____________________ No. of passengers carried at the time of accident ________
Please enclose self signed copies of Route Permit and Fitness Certificate.

DECLARATION
I/We agree to provide additional information to the Company, if required. I/We the above named insured, do hereby, to the best of my/our knowledge
and belief, warrant the truth of the foregoing statement in every respect, and if 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 thereunder in respect of past or future claims shall be forfeited. I understand that the Company reserves the right of verification of
facts and documents relating to the policy and claim.

Place :________________ __________________________


Date: D D M M Y Y Y Y Signature of Insured
Universal Sompo General Insurance Co. Ltd.
Page No. 2

DETAILS OF DEATH/INJURY/PROPERTY DAMAGE TO THIRD PARTIES/OCCUPANTS/DRIVER


Sr Name of Address Contact No. Nature – Death Name of the Any Legal/Court
no Driver/Passenger/Third Party (Village/Town) / Injury / Hospital if Notice Recd.
Person/Third Party Property Property admitted
Damage

N.B. Please attach additional sheet with full particulars, if needed.

OTHER INSURANCE (Is this vehicle insured with any other Insurer): Yes / No (If Yes, please fill following information)
Name of Insurance Company
Period of Insurance
Sum Insured
Policy issued at
Whether claim lodged against this Insurer
Additional Information (if any):

DECLARATION
I/We agree to provide additional information to the Company, if required. I/We the above named insured, do hereby, to the best of my/our knowledge
and belief, warrant the truth of the foregoing statement in every respect, and if 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 thereunder in respect of past or future claims shall be forfeited. I understand that the Company reserves the right of verification of
facts and documents relating to the policy and claim.

Place :________________ __________________________


Date: D D M M Y Y Y Y Signature of Insured

----------------------------------------------------------------------------------------------------------------------------------------------------

DISCHARGE VOUCHER

I/We hereby acknowledge having received a sum of Rs. _____________ (Rupees _________________________________________) from Universal
Sompo General Insurance Co. Ltd. towards full and final settlement of my/our claim under Policy No. _________________________________________
in respect of damage caused to my/our vehicle no. _____________________ in an accident which occurred on ____/____/__________ and claim
lodged by me under Claim No. _________________, which is to my complete satisfaction.

Place :________________ __________________________


Date: D D M M Y Y Y Y Signature of Insured

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