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Claim Form

This document is a Motor OD Claim Form from United India Insurance Company Limited, intended for reporting vehicle accidents or thefts. It collects essential information including insured details, vehicle information, accident specifics, and declarations by the insured. The form emphasizes that its issuance does not imply admission of liability by the insurance company.

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63 views1 page

Claim Form

This document is a Motor OD Claim Form from United India Insurance Company Limited, intended for reporting vehicle accidents or thefts. It collects essential information including insured details, vehicle information, accident specifics, and declarations by the insured. The form emphasizes that its issuance does not imply admission of liability by the insurance company.

Uploaded by

parthasurveyor
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 - 500 014.


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

Policy No
lnsuredDetails: lnsured Name
n SU red Ad dress: fif6, 19, AA, 6€ APr*zl..ieu N
Vcr'tt v Rv Avt A, Cp La^tY , k ee L kATTAIJ$.
Pin Code: 6Aa t E State li^.re lJltltt
Mobile: g6un1 oi7;€? E-Mai I : V f rl i rtg.r6ra l^l ot,r,. {A -4Aa I I t ( t ;7-t
Aadhar No PAN No
Bank Account Account No Bank Name LL I irl/
Deta ils: IFSC Code No Name: b aL,
Branch traTt) ,t .ai
Vehicle Details: Registration No: fp-91_Av 7e +C Make: OJ -Je^t z Model: \t A14eth Q lf
Engine ruo. ffiX A/J. f *rr"r,, ,rtilTl Chassis No.
Date & Place of Date of Loss: Time ) A.N/.1P.M.
Loss: Place of Accident / Theft: Nefulvlt*Am tyrrlnv RuAD, lntt v$l&2l$Pe*$l $rtOtctt,
I
Driver details Drlver Name V R Vrvst.<.Lrr
Driving Licence No / Expiry Date: Tr*r .l-q -'t,rlz.rir,a ,gaF(
Accident Details :
h,;2 Lo i^q1 b,'x.., brry Su)de^,w, lwrct
nS Clllorl<- ot}. 7-,iorrrn

w
Provide brief
a,al trle gt 6,'e.;J Fcr,t clar,ra, ia fi.*Ylod/ &,
d escri pti on
e( b H
No of Occupants carried: S rru a-Ll*
Workshop Details: Name & Address of workshop'
Btt<ELz, No,loq r la,t(,N .&oir), Aun^*,cil6^ttyil.
Workshop Mobile: 6a1n tAz*o f mail : ltrcav.f- ty a rho Lt A Estimate Amount: Rs. Iee. fAR ra
Theft Claim Theft of Vehicle: Yes / No Deta ils Ekl,'cai- I

Theft of Accessories: Yes / No Details

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


Date of reporting to Police: lL -OX nlA,u FIR/Crimediary numbet e. t,CC q l3 ne
Third Party Loss Any lnjury/Death to Driver YeslNo Deta ils:
Deta ils

Any TP lnjury/Death: Yes/No Deta ils:

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

Any TP Property Damage: Yes/No Details:

DECLARATION BY THE INSURED


l/We the above named, do hereby, to the best of nry/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 recoverthereunderin respect of past orfuture accidents shall be forfeited
Date';27 lo+ lJ +
fl!!9. l<ar^ chi lraFtrr! r
ty
Signatrfre of lnsured / Claimant

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