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    Motor - Claim Form PDF

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    arvind gaikwad
    This document appears to be a motor claim form for Reliance General Insurance that collects personal and vehicle details of the claimant as well as details of the accident in order to process an insurance claim. It requests information such as the policy and vehicle numbers, names and addresses of those involved, what happened in the accident, and vehicle repair details. The form concludes by having the claimant declare that the information provided is true and correct.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Motor - Claim Form PDF

    Uploaded by

    arvind gaikwad
    2K views2 pages
    This document appears to be a motor claim form for Reliance General Insurance that collects personal and vehicle details of the claimant as well as details of the accident in order to process an insurance claim. It requests information such as the policy and vehicle numbers, names and addresses of those involved, what happened in the accident, and vehicle repair details. The form concludes by having the claimant declare that the information provided is true and correct.

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    MOTOR - CLAIM FORM.pdf

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    This document appears to be a motor claim form for Reliance General Insurance that collects personal and vehicle details of the claimant as well as details of the accident in order to process an insurance claim. It requests information such as the policy and vehicle numbers, names and addresses of those involved, what happened in the accident, and vehicle repair details. The form concludes by having the claimant declare that the information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views2 pages

    Motor - Claim Form PDF

    Uploaded by

    arvind gaikwad
    This document appears to be a motor claim form for Reliance General Insurance that collects personal and vehicle details of the claimant as well as details of the accident in order to process an insurance claim. It requests information such as the policy and vehicle numbers, names and addresses of those involved, what happened in the accident, and vehicle repair details. The form concludes by having the claimant declare that the information provided is true and correct.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    General Insurance A Reliance Capital Company

    Call 3033 8282


    Motor Claim Form www.reliancegeneral.co.in
    (Issuance of this Form does not imply acceptance of the liability)

    Personal Details of proposer (Owner) (To be filled in block capitals)

    Policy No. Cover Note No.

    Policy Period

    Full Name Mr. Mrs.

    Address for Communication

    Flat Building

    Road/Street/Sector

    Area

    Taluka/Village/District/City Pin Code

    State Country

    Phone Mobile

    Email Fax
    Bank Details required for Electronic clearing cheque
    Name of the Bank

    Branch

    Account No. MICR Code

    Vehicle Details
    Registration No. Engine No

    Chassis No. Model

    Make Date of Registration

    Financiers incase if any

    Details of Accident

    Date Time

    Place

    Name of P. S. Police FIR No.

    Name of Garage

    Estimate of Loss Garage Ph. No.

    No. of Persons Traveling at the time of Accident

    Please narrate the accident (Do not state "Police Report attachment" or "as per policy report") (Please attach a separate sheet if needed)

    For what purpose was the vehicle being used at the time of accident ?

    Vehicle repair satisfaction voucher


    Claim No.
    I/ We hereby acknowledge having received from garage my/our Motor vehicle
    bearing Registration Number Which has been repaired to my/our satisfaction and I/we admit that the payment of Rs.
    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
    Date Name
    Driver at time of Accident

    Name

    Date of Birth Licence No.

    Licensing Authority Valid Upto

    Type of Vehicle authorised to Drive

    Is the Driver Owner Paid Driver Any Other Person If any other person, Please specify

    Details Required only for commercial Vehicle

    Registered load carrying capacity Load carried at time of Accident

    G. R. date and No. G. R. Issued by

    Authorised Passanger Capacity No. of Passanger carried at time of Accident

    Permit No. Permit Issuing Authority

    Permit Valid upto Permit Valid for (Area)

    Permit Issuance Date Fitness Granting Authority

    Date of Last Fitness Exam. Fitness Valid upto

    If there is a third party property damage or injury


    Injury / Death / Passanger / Dr. / Lab. /
    Type of T. P. Loss Status of victim
    Property damage Third person

    Information required for theft, burglary claims

    Place of theft Time Noticed Date of theft

    Police Station FIR No.

    Details of any other Insurance cover this vehicle

    Detail of any other Insurance covering this Vehicle

    Name of Insurance Company

    Policy No. Period of Insurance

    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 forefeited.

    Place Signature of the Insured

    Date
    Registered Office: Reliance General Insurance Co. Ltd., 19, Reliance Centre, Walchand Hirachand Marg, Ballard Estate, Mumbai - 400 038,India
    Version No. 1.0, July 2006

    Registered & Corporate Office Address


    Reliance General Insurance Co. Ltd.
    Registered Office : 19, Reliance Centre, Walchand Hirachand Marg, Ballard Estate, Mumbai - 400 038.

    Corporate Office : 5th Floor, N. K. M. International House, 178, Backbay Reclamation, Babubhai Chinai Road, Mumbai - 400 020.

    For further assistance call 3033 8282.

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