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Future Generali - Motor Insurance Claim Form

The Motor Insurance Claim Form must be filled out and signed by the insured, providing accurate details about the accident and vehicle. It includes sections for personal information, loss details, driver information, and declarations regarding the truthfulness of the information provided. The form also requires submission of supporting documents and emphasizes that its issuance does not imply liability.

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gangane14
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35 views2 pages

Future Generali - Motor Insurance Claim Form

The Motor Insurance Claim Form must be filled out and signed by the insured, providing accurate details about the accident and vehicle. It includes sections for personal information, loss details, driver information, and declarations regarding the truthfulness of the information provided. The form also requires submission of supporting documents and emphasizes that its issuance does not imply liability.

Uploaded by

gangane14
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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Motor Insurance Claim Form

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

a. The claim form is to be duly filled and signed by the insured.


b. All facts and statements must be factual not influenced or biased in any favor.
c. The damaged vehicle must be parked at safe place to avoid any subsequent loss/Theft

Policy Number Claim Number


Vehicle Number
Insured Details
Please fill in your current correspondence address. Where you want us to send letters/communication for this claim

Name
Address
City Pin
Mobile Landline
Email ID
Loss Details
Date & Time of accident D D M M Y Y _____ am/pm
Place of accident
Type of Loss Own Damage Theft *Third Party
Short Description of
Accident

Police Report Details, If any ___________________________________________________________________


Driver details at the time of accident
Name Age
Driving License No. Name of RTO
Learners License □ Yes □ No
Co passenger
details
*Please fill the details overleaf for third party damage.
Declaration
I/We hereby declare that the details given above are true and correct to the best of my belief and knowledge. In the event
above information or any part thereof is found incorrect, I agree that all right under the policy will be forfeited.
I also declare that there was/ was no third party bodily injury or property damage involve in accident.

Date Signature of Insured

Corporate Office Address:


001 Trade Plaza, 414 Veer Savarkar Marg, Prabhadevi, Dadar West, Mumbai 400025
Telephone: 40976666
Applicable for commercial vehicle:
No. of Passenger carried at the time of
accident G R Number & Date
Permit No Permit Issuing Authority
Permit Valid up to Permit valid for (Area)
Fitness Granting Authority Fitness valid up to

Applicable for third party property damage or injury


Name of Third Contact No Type of Injury Name of the Hospital Any Legal/
Party/Occupants where admitted Court Notice
/Driver Received

I hereby declare having submitted the following documents:


Copy of Policy/Cover Note Copy of Fitness Certificate
Copy of RC Book Copy of Permit
Copy of Driving License Copy of FIR
Estimate of Repairs G.R Form

DECLARATION

I/We here by declare that the details given above are true and correct to the best of my belief and
knowledge .In event above information or nay part thereof is found incorrect, I agree that all rights
under the policy will be fortified. I/We also agree to provide additional information to the company,
if required.

Date Signature of Insured

Corporate Office Address:


001 Trade Plaza, 414 Veer Savarkar Marg, Prabhadevi, Dadar West, Mumbai 400025
Telephone: 40976666

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