Intimation Cum Preliminary Claim Form – Auto Policy

Please keep the information handy before ringing up the 24X7 call center at
1800-119966 or SMS CLAIMS to 8888
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY.
PLEASE SIGN ON BOTH SIDES OF CLAIM FORM. DO NOT LEAVE ANY COLUMN UNANSWERED.

Claim No. ____________________ Policy no. 064001/0185061758000000/00

___________________
KA-05-QB-3321
Vehicle No. ___________________ ABCRX181865
Eng No._________________________ MYHAABCA1RBD36645
Chassis No.__________________

VINAY PRASAD.S VINAYPRASAD271@GMAIL.COM

INSURED/CLAIMANT NAME: _____________________________________email:____________________

#16/A SRI AYYAPPA NILAYA 8TH MAIN 6TH CROSS BALAJI LAYOUT NEAR INDIAN OVER SEAS BANK
Address: ___________________________________________________________________________________________
SAHAKARNAGAR POST BANGALORE 560092
_________________________________________________________________City_______________Pin_____________
+91 9008057666
Mob ____________________________ Tel Res _________________________ Tel off ____________________________

Time & Date of Accident / Occurrence 60.00 Hrs 2 3 / 0 6 / 2 0 2 4 Placeof Accident ITMADDU
Type of Loss (details overleaf) OWN DAMAGE THIRD PARTY Bodily Injury Property
FORK BEND,
Damage Short Description of Accident/Incidence (Sketch overleaf) ____________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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 ________

Police FIR no. (lodge if any) ____________________________________

Details of the driver at the subject time of accident

SATHYA NARAYANA.G
• Name _____________________________________________________ Age _____ STORE INCHARGE
32 Occupation_________________
• Driver is Owner Paid Driver Relative/ Friend
KA
• Driving License No. _________________________________ Badge no ________________________
• Effective for (type of vehicle)______________________________Effective upto:______________________________
Please enclose self – certified copies of Registration Certificate and Driving License (by the insured). Also please enclose copies of Police Report and Fire
Brigade Report, if lodged.

DECLARATION

I/We agree to provide additional information to the Company, if required. 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 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 accidents 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 the Insured
CLAIMS DEPARTMENT
Tata AIG General Insurance Company Ltd.
Ahura Centre, 4th Floor, 82, Mahakali Caves Road, Andheri (E), Mumbai-400093 P.T.O
DETAILS OF DEATH/INJURY/PROPERTY DAMAGE TO THIRD PARTIES/OCCUPANTS/DRIVER

Sr Name of Address Contact No. Type of Injury/ Name of the Doctor Any Legal/Court
no Third Party/Occupant/Driver (Village/Town) Damage Hospital where Attending Notice Recd.
admitted

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

Show how the accident occurred by using this diagram

Give street names, direction and location of objects concerned

DECLARATION

I/We agree to provide additional information to the Company, if required. 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 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 accidents shall be forfeited.
I understand that the Company reserves the right of verification (*) of facts and documents relating to the policy and claim.

Place BANGALORE
Date: 2 6 0 6 2 0 2 4 Signature of the Insured

CLAIMS DEPARTMENT
Tata AIG General Insurance Company Ltd.
Ahura Centre, 4th Floor, 82, Mahakali Caves Road, Andheri (E), Mumbai-400093. Fax: +91 22 56938171
(Regd. Office: Peninsula Corporate Park, Nicholas Piramal Towers, 9th Floor, G K Marg, Lower Parel Mumbai - 400013)
Date:

To,
Tata-AIG General Insurance Co. Ltd.
2nd Floor, #69, Millers Road,
J. P. & Devi Jambukeshwar Arcade,
Bangalore-560052

Sub.: Satisfaction Letter/ Discharge Voucher

064001/0185061758000000/00
Claim Number-__________________________Policy Number-_____________________________

KA-05-QB-3321 10077414099
Vehicle Number__________________________A/c.-_____________________________________

Dear Sir/ Madam:

After inspecting my vehicle repaired by M/s.______________________________________________

I/we hereby confirm that the damages claimed by me/us under the above mentioned claim have been

repaired to my/our utmost satisfaction. I/we request you to kindly pay the claim amount of

Rs.____________(Rupees_______________________________________________________) directly

to them. I/we have paid the amount of Rs.____________(Rupees______________________________)

towards depreciation and/or extra work done on my/our vehicle.

I/we accept the settlement in full and final and discharge of all liabilities arising out of this claim upon

Tata-AIG General Insurance Co. Ltd.

Regards,

Signature of Insured
Name__________________________
Rubber Stamp in case insured is a firm