MOTOR CLAIM FORM

(Issuance of this form does not imply acceptance of the liability)

All fields in the form are mandatory

a. The claim form is to be filled in CAPITAL LETTERS & duly signed by the insured.
b. All facts and statements must be factual, not influenced or biased in any form.
c. The damaged vehicle must be parked at safe place to avoid any subsequent loss/theft. Company will not be responsible for
the same.
d. Please read carefully the attached list of documents required to speed up processing of your claim.

Policy Number:
Claim Number:

Insured Details
Insured Name: Address:
City: State: Pin Code:
Contact No. 1: Contact No. 2:
Mail ID:

Vehicle Details
Vehicle No: Chassis No:
Engine No: Make:
Model: Registration Date: D D M M Y Y Y Y

Details of Accident/Theft
Date: D D M M Y Y Y Y Time: H H : M M Place: No. of occupants excluding driver:
Purpose of Travel: Description of Accident:

Driver Details
Driver Name: Mr/Mrs/Miss
Licence No: Type of vehicle authorised to drive:
Learner Licence: Yes No Expiry Date: D D M M Y Y Y Y Contact No:
Relationship with Insured: Date of Birth: D D M M Y Y Y Y

Qualification: Occupation:

Bank details for NEFT payment (Please attach a cancelled cheque)

Bank Name: Branch name:
IFSC Code :
Account Number: Signature of Insured

Additional Details for Commercial Vehicles

Permit No: Valid up to: D D M M Y Y Y Y

Load Challan date: D D M M Y Y Y Y Fitness no:

Valid up to: D D M M Y Y Y Y Load Challan Weight:

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 Third Party Death/Injury/Personal Accident Details
Name of Person Whether TP/ Contact Number Injury/ Details of Any Legal/Court
Passenger Death Notice Received.

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 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 Signature of Insured:
Place:

Documents required for Accidental claims Documents required for Theft Claims Documents required for PA & TP claims
1. Claim Form Duly signed by Insured 1. Claim Form Duly signed by Insured Personal Accident:
2. Registration Certificate copy of the vehicle 2. Original Policy Document 1. Death Certificate
3. Driving Licence 3. Original Registration Certificate, Permit, 2. Post-mortem report
4. FIR or Police Panchanama copy Fitness, Tax. 3. Legal Heir certificate
5. Repair Estimate 4. All original keys/Service Booklet/ Warranty 4. Certificate of Disablement, in case of
6. Repair bills and payment proof/ Discharge Card/ Original purchase invoice. permanent partial disability
Voucher. 5. Police Panchanama/FIR and Final report/ TP Claims:
7. Documents required by AML guideline. Non Traceable report. 1. Insurance Policy copy
Additional documents required for 6. Acknowledged copy of letter addressed to 2. Claim Form duly signed
Commercial vehicle: RTO intimating theft and forming ‘NON-USE’. 3. Police FIR Copy
1. Fitness certificate 7. RTO Transfer papers duly signed. 4. Registration Certificate copy
2. Permit certificate 8. Consent towards agreed claim settlement 5. Driving License copy
3. Road Tax receipts value from yourself and Financier. 6. MACT/Legal Notice
4. Load Challan 9. NOC from the Financier if claim is to be 7. Claimant details
settled in your favour. 8. Supporting documents
10. Subrogation Letter, Indemnity bond and
Discharge voucher.
11. Documents required by AML guideline.
Additional documents in specific claims shall be intimated separately.

Discharge cum Satisfaction Voucher ( Motor Claim)

Claim Number: Vehicle Number:
I/We hereby taking delivery of the vehicle from ________________________________________which has been repaired to my/our
complete satisfaction and I/We authorise our Insurer Edelweiss General Insurance Company Limited to make the payment of
`.________________ to the workshop towards Full & Final settlement of the above claim. I/We are fully satisfied with the Full & Final settlement
of my/our claim on the policy number________________________________________ and herewith discharge the Insurer from all
liabilities arising out of this claim.
I/We hereby also subrogate all my/our rights and remedies to the company in respect of the above loss/damage.

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

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Edelweiss General Insurance Company Limited, Corporate Office: 5th Floor, Tower 3, Kohinoor City Mall, Kohinoor City, Kirol Road, Kurla (West), Mumbai - 400070., Registered Office: Edelweiss
House, Off CST Road, Kalina, Mumbai -400 098 I IRDAI Regn No: 159 I CIN: U66000MH2016PLC273758 I Reach us on: 1800 12000 I Email: support@edelweissinsurance.com
Website: www.edelweissinsurance.com I Trade logo displayed above belongs to Edelweiss Financial Services Limited and is used by Edelweiss General Insurance Company Limited under license.
Insurance is the subject matter of solicitation.