MOTOR INSURANCE CLAIM FORM

ISSUEOFTHISFORI\iDOESNOTIMPLYACCEPTANCE
OFLIABILITY.
PLEAS
E GIVEALLTHEDETAILS
ASKE
D FORNTI.]ECLA]MFORM
CLAIMFORMTOBEF LLEDNANDSIGNED
BYTHEINSUREDONLY

PolicyNo ClaimNo (Forofficeuseonly)

EngineNo No
Chassis

Name
AA0rcSS
[4obile
No E-l,,lald
Delalsofolherexisting policy
nsurance (ies)inrespectoilhis
accjdenl

Date& T meoiAccideit/
occurcnce Placeo' Loss_
oflossr! Damagetr Theft n Third
Type Party Estimated
Costof Repal
ShortDescrption
ofAccdenUncde

Name Age
ls Diverl ! ts40 unvel L Ke altve/fneno

Driving
Llcense
No Vadlpto
Authosedio dive lssuiigAuthoty

Permit
No ValdUplo lssungAulhorly
FtnessCedificale
ValidUplo No.offarepaying
Passengels
carried
WeghtandNature
of Goods
Carried GR/LR
No

Police
Repod tr Yes tr No, fyes,FIR/GD
Lodged: No Police
Station
Name
Death/lnjuryto
anyoccupanl
/ThrdParty (others)
and/or
ThrdParty Damage: n Yes
Property \0
Delails
incaseofDeath
and/ornjurytoThirdParty/occupan toproperty:
ts/Drverordamage

1,4/Ve
lheabovenamed, dohercby, to thebestof my/our knowledge andbeliefwarfanl
lhelruthof lheforego
ngstaternent
n
everyrcspectandMe agree thalil l/Wehavernade of n anyfurthe
r declafation
thecornpa
nymayrequ reinrespectoflhesaid
accdent,shallmake anyfalseoffraudu entstatemenl oranysuppression orconcealmentlhepolcyshallbe vodandal ighlio
recover jn respect
lhere'under of paslorfutureaccdentsshallbeforfeiied lundersland
thatthecompany reserves
therghtof
veiicaUonoffactsanddocuments relatingto policy
andtheclairn.
Date Place Sgnalure
oflheInsLrred
attacha photocopy
N.B.Pleas€ ofyourblank/ cancelled for NEFTpuryose.
cheque

NationalInsuranceCompanyLimited,
RegstercdOffice:- 3, Middetonstreet,Kolkata-700071
IRDARegstraton No 58