Claim No.

: __________________

Motor Claim Form

(Issuance of this form does not imply acceptance of the liability) All fields in the form are mandatory

Personal Details of Claimant (Owner) To be filled in BLOCK LETTERS

Policy No. Cover Note No.

Policy Period From D D / M M / Y Y Y Y To D D / M M / Y Y Y Y

Full Name o Mr. o Mrs. o Ms. F I R S T M I D D L E L A S T

Address for Communication

Flat Building

Road/Street/Sector

Nearest Landmark Area

Taluka/Village/District/City Pin Code

State

Change of the contact Details o Yes, I wish to change my contact details o There is no change in my contact details
Please update mentioned mobile number as primary contact details against my policy. I also hereby confirm to be contacted on the number provided
above for Claim Status /Policy Renewal.

Phone No. Mobile No.

WhatsApp No. Alternate Mobile No.

Email ID D.O.B. D D / M M / Y Y Y Y

Aadhaar (UIDAI) No. PAN No.

o Private Service o Self Employed o Politician o Retired o Student o Government Service
Insured Profession
o House Wife
Monthly Income o Upto ` 20,000 o ` 20,001 to ` 50,000 o ` 50,001 to ` 1,00,000 o ` 1,00,001 and above
Any claims made in last two
o Yes o No If yes, please specify ______________________________________________________
insurance policies

Vehicle Details

Registration No. Date of Registration D D / M M / Y Y Y Y

Expiry of Temp. Reg
Date of Purchase of Vehicle D D / M M / Y Y Y Y D D / M M / Y Y Y Y
(If applicable)

Chassis No. Engine No.

Make Model

Class of Vehicle o Pvt o Two Wheeler o Commercial

Financiers o Yes o No If yes, Name of Financier _________________________________________________

Vehicle fitted with Anti
Vehicle fitted with LPG/ CNG o Yes o No o Yes o No
theft device

reliancegeneral.co.in 022 4890 3009 (Paid) 74004 22200 (WhatsApp)

IRDAI Registration No. 103. Reliance General Insurance Company Limited. An ISO 9001:2015 Certified Company
For complete details on the benefits, coverage, terms & conditions and exclusions, do read the sales brochure, prospectus and policy wordings
carefully before concluding sale. Registered & Corporate Office: 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off.
Western Express Highway, Goregaon (E), Mumbai-400063. Corporate Identity Number: U66603MH2000PLC128300. Trade Logo displayed above
belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Motor Claim
Motor Claim Form.
Form. RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.
RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.
 Details of accident

Date D D / M M / Y Y Y Y Time H H / M M am/pm

Vehicle Speed

Place of accident Odometer reading

Police FIR No. / GD Entery
Name of Police Station
(Lodged if any)
Name of Garage

Estimate of Loss Garage Ph. No.

No. of persons traveling at the
time of accident excluding driver
Description of the accident
(Please attach a separate sheet
if needed)
For what purpose was the
vehicle being used at the time of o Personal o For Hire of Passenger o Carriage of Goods
accident?
Vehicle was plying from _______________________________________ to ___________________________________________
Was any third party involve in
o Yes o No If Yes, Vehicle No. and details ______________________________________________
the accident
Diagram of location of accident, position of your vehicle, direction in which you vehicle was moving. Street name, nearest landmark/
shop/building

Kindly shade the damaged portion

Sample Layout
right side
top
front rear
under Body
left side

Driver at time of accident

Name

Correspondence Address

Telephone Number Gender Male / Female

Date of Birth D D / M M / Y Y Y Y Licence No.

Licensing Authority Valid upto D D / M M / Y Y Y Y

Type of Vehicle authorised to
o HGV o Transport o LMV o Motor Cycle o Scooter Without Gear
Drive:
Is the Driver: o Owner o Paid Driver o Any Other Person, please specify _______________________________
Was the driver under the
o Yes o No Type of Licence: o Permanent o Learner
influence of alcohol:
Driver involve in any other
o Yes o No If yes, please provide details ____________________________________________
accident in last two years

Details required only for Commercial Vehicle

Nature of load carried at time of G. R. Date D D / M M / Y Y Y Y
accident and No.
No. of passengers carried at
Permit No.
time of accident
Permit valid upto Permit Issuance Date D D / M M / Y Y Y Y

Fitness valid upto

Motor Claim Form. RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.

 If there is a third party property damage or injury
Injury / Death / Passenger / Driver /
Type of T. P. Loss Status of victim
Property damage Third person

Additional information required for theft claim

Place of theft Time noticed H H / M M am/pm

Date of Theft D D / M M / Y Y Y Y Police Station

FIR No. Date of FIR D D / M M / Y Y Y Y

By whom it was first noticed and
Time H H / M M am/pm
when:

Witnesses Name & Address

Details of person in whose

Witness Contact No possession the vehicle was at
the time of theft
Relationship Purpose

Add On's
Do you wish to opt a claim for
add on cover if opted under the o Yes o No
policy
o Nil Depreciation o Consumable expenses o Engine Protector o Return to Invoice
o Total Cover o Others
Please Specify _____________________________________________________________________________________
Details of any other insurance
covering this vehicle (Name of
Insurance Company)
Policy No.

Period of insurance

Bank Details for NEFT payment (For Reimbursement Claims)

Name of the Bank Account Holder o Mr. o Mrs. o Ms. F I R S T M I D D L E L A S T

Bank Account No. Account: o Saving o Current

Name of the Bank

Branch
MICR Code (9 digit MICR code number of the bank and branch appearing on the
cheque issued by the bank)
IFSC Code (11 character code appearing on your cheque leaf)
o I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank
Account.*
*As per IRDAI, its mandatory that all payments made to the insured are only through electronic mode.
Note: Please attach original cancelled cheque and a copy of PAN card for verification of the particulars

Motor Claim Form. RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.

 PEP Declaration:

Are you a Politically Exposed Person (PEP)? o Yes o No

If yes, please mention the position held

Is any of your close relation or family member a PEP? o Yes o No

If yes, please mention the name and relation and the position held
by such close relative/family member.
I hereby declare that in future if me, any of my close relatives or any of my family member attains a position of PEP then I shall confirm the
same to Reliance General Insurance Co. Ltd as a mandate. I understand that this is a crucial information under the PMLA Rules and AML/
CFT Guidelines and shall confirm that the answers given by me is true. In case the company comes to know that this is a misrepresentation
and concealment of information then the policy shall be put on hold for scrutiny by the company and I shall be solely responsible for
the same.
Note :
“Politically Exposed Persons” (PEPs) shall have the meaning assigned to it under sub clause (db) of clause (1) of Rule 2 of the Prevention of
Money Laundering (Maintenance of Records) Rules, 2005.”
(db) “Politically Exposed Persons” (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country,
including the heads of States or Governments, senior politicians, senior government or judicial or military officers, senior executives of state-
owned corporations and important political party officials”.

AML Guidelines
1. I/We hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been /will be paid out of
proceeds of crime related to any of the offense listed in Prevention of Money Laundering Act,2002.
2. I Understand that the Company has the right to call for document to established sources of funds.
3. The Insurance Company has right to cancel the insurance contract in case I am/have been found guilty by competent court of law under
any of the statutes, directly or indirectly governing the prevention of money laundering in India.
Place: ___________________________
Date: ____________________________

________________________________
Signature of Proposer

General Declaration:
I understand that as per the new AML/CFT Guidelines issued Reliance General Insurance Co. Ltd will be verifying my details pertaining to
KYC and PAN provided at the time of proposal.
I further, do hereby agree and consent that in the case of the event of a mismatch of information provided by me in the proposal form,
identification proof, and address proof at the time of issuance of the policy. I request Reliance General Insurance Company Limited to issue
the policy with the details appearing as per my proposal form. I will be solely responsible for any consequences arising out of the difference
in detail given by me during the verification of supporting documents provided by me at the time of issuance of the policy or otherwise.

Motor Claim Form. RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.

 Claim Procedure: Step-by-Step Guide for Claims

Registration of Claim
Claim has to be intimated with our Call Centre at 022 4890 3009 (paid).
Intimate the claim to the insurance company immediately. Delay in intimation would tantamount to a violation of policy condition.

First Step
• Please provide your mobile no. for sending SMS about your claim status from time to time.
• If there has been any injury to any passengers or a head on collision resulting in major damages or vehicle not in a motorable
condition due to accident please report the matter to Police and seek a spot survey immediately before shifting the vehicle from the
accident spot.
• Please rush the injured to the hospital.
• You can seek the help of our Call Centre Executives in identifying a cashless network garage* close to the location of loss.
• Decide on the repairer and inform us immediately once the vehicle is left at the garage.
• Please try to produce the vehicle for inspection as early as possible as the policy does not pay for consequential/aggravated
damages on account of delay.
• Submit all documents listed on time for a speedier claim settlement.**
• Keep original documents ready for verification by our loss assessor.
• Produce the vehicle for re-inspection after repairs if the loss is above Rs.50,000. Submit bills and cash receipt within 5 days from the
date of repair.
• To pay the difference bill amount over and above the liability of the insurance company before taking delivery of the vehicle from our
cashless network garage, which can be on account of depreciation, excess, consumables etc.
• We suggest you to opt for a NEFT (electronic fund transfer to your bank account directly) for a hassle free claim settlement, if you have
not chosen to repair at our cashless network garage.
• In case of a loss due to riots inform police immediately.
• If loss is on account of fire, intimate fire brigade immediately and try to minimise loss.
• In case of a theft claim, report the loss immediately to the insurance company and also the police. Informing insurers immediately
helps us co-ordinate with the police for tracing of the vehicle through the investigator.
• To co-operate with the investigator in a theft claim and provide necessary information sought by him.
• If you would like to lodge a claim under the personal accident cover of the policy for death or permanent total disablement or loss of
limbs or eyes*** do intimate the call centre executive of the same.
*Conditions apply
**Claim amount shall be subject to the policy terms and conditions and there shall be deduction for depreciation, excess etc. as laid down in the policy
terms.
Please go through the policy document
***Please refer Section III of the policy document
*For Theft claims : GPS coordinates at the time of loss & present / Dash Cams will be obtained
*For OD Claims: Crash report and GPS coordinates / Dash Cams (for OD / TP Claims) will be obtained
This is solely for the purpose of claim processing

Documents to be kept ready at the time of registration of a claim

• Policy Copy • Registration Book • Driving License
You may have to inform the insurer of the following at the time of intimation of a claim:
• How the accident took place • The damages suffered by the vehicle • Location of the accident
• Location, where the vehicle is available for inspection • Injuries to passengers/driver/third parties if any
• Name and particulars of driver who was driving the vehicle at the time of accident

Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance
Company Limited under License.

"
Vehicle repair satisfaction voucher (For Cashless Settlement)
Claim No._________________________________________
I/ We hereby acknowledge having received from Name of the garage garage my/our Make & Model vehicle
bearing Registration Number Registration No. Which has been repaired to my/our satisfaction and I/we admit that the
payment of ` ____________________________________ on account of such repair by Reliance General Insurance Company Limited to
the above garage is in full discharge of my/our claim upon the said company under Policy No._________________________ in respect of
the damage caused to the above mentioned vehicle in an accident which occured on_____________________________.

Place _________________________________ Signature of the Insured: ____________________________

Date __________________________________ Name of Insured: _________________________________

Motor Claim Form. RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.

 Documents required for processing of a claim
General Documents applicable for all type of losses Own Damage Theft of vehicle Personal Accident Claim

Claim Form filled-up completely & duly signed* ü ü ü

Policy Copy ü ü ü

RC with RTO Tax Receipt** ü ü û

Driving Licence Copy** ü û û

Original Estimate of Repair ü û û

Original Repair Invoice and payment receipt ü û û

FIR Copy (in case of major loss and theft) ü ü û

OWN DAMAGE

Fire Brigade report for fire loss ü û û

Cancelled Cheque for fund transfer or Self attested Aadhaar Card Copy (if opted) ü ü ü

KYC document for high value claim ü ü ü

Bank details for the payment for EMI protector ü û û

Loan documents for EMI payment for EMI protector ü û û

Auto Loan Account No. ü û û

Purchase Invoice Copy ü û û

Vehicle Fitness Certificate Copy*** ü ü û

Vehicle Permit and Authorisation Copy*** ü ü û

Load Challan for goods vehicle*** ü û û

Passenger list for passenger carrying vehicle*** ü û û

Non Traceable report û ü û

All Original Keys û ü û

Additional documents for

Letter of subrogation and indemnity û ü û

Theft of vehicle

Loan account statement from the Financier û ü û

NOC from the Financier (if hypothecated) û ü û

Form 35 duly signed û ü û

Form 28, 29 and 30 duly signed û ü û

Letter to RTO intimating them of the theft û ü û

Hospital Certificate/documents û û ü

Death Certificate û û ü
Accident Claim

Post Mortem Certificate û û ü

Personal

Legal Heir Certificate/Will/Proof of nomination û û ü

Affidavit on non judicial stamp paper û û ü

Certificate of disablement in case of a permanent partial disability û û ü

*Stamp required in case of company

**Original document to be produced for verification of the driver at the time of accident
***Applicable for commercial vehicles only
In case if necessary, additional documents may be require for processing of a claim

Track your claim status

You can always track your claim status -
• On our website - www.reliancegeneral.co.in, in the 'Claims' section or
• Through the Automated Interactive Voice Recorder System at our Call Centre or speak to our Call Centre Executives at 022 4890 3009 (paid) or
• SMS claimstatus<space><claim number> at 9266334477 to get the claim status

Registered & Corporate Office Address

IRDAI Registration No. 103.
Reliance General Insurance Company Limited. Registered & Corporate Office: 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off. Western
Expres Highway, Goregaon (E), Mumbai-400063.
For any assistance call (022) 4890 3009 (Paid)

"
Claim Discharge Voucher (For Reimbursement Claims)
In consideration of approval of my /our claim, I /we hereby accept from Reliance General Insurance Company Limited the sum of ` _____________
Rupees (amount in words) ________________________________________in full and final settlement of my/our claim.
I / we hereby voluntarily give discharge receipt to the company in full and final settlement of all my / our claims present or future arising directly
indirectly in respect of the said loss/accident. I /we hereby also subrogate all my/our rights and remedies to the company in respect of the loss/
damage.
Claim No : _________________________________________ Signature of Insured: ________________________________________
Policy No : ___________________________ Name of Insured: ___________________________________________
Date of loss: ___________________________ Date: _____________________________________________________
Note:
• In case of firm/company owned vehicles stamp & sign of authorized signatory is required.
• Issuance of this voucher is not to be taken as admission of liability.

Motor Claim Form. RGI/MCOM/CO/MOT-02/CLM-FM/Ver.1.0/180325.