Motor Insurance Claim Form

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

As soon as Loss or Damage has become known we should be notified without delay. If any details are unavailable, they may be sent later after submission of this form.

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

B. Please fill this form in Block Letters and Tick the Boxes where appropriate and do not leave any column unanswered.

Policy Number * Vehicle Number * Claim Number *

Class of Vehicle *:

Insured Details

Insured Claimant Name * Address * City * Pin Code * State *
Mobile No.Mobile Number *
Alternate Mobile Number *
Office Residence Email ID * Alternate Email ID *

NEFT Details

Bank Name Bank Branch State City MICR Code IFSC Code Payee Name Payee Account Number UPI/Wallet ID

Loss Details

Date & Time of Accident* Place of Accident*

Type of Loss *:

Short Description of Accident*

Driver Details at the time of Accident

Was your vehicle parked at the time of accident*?

Please enter driver details

Name * Age * Occupation * Contact No * Driving License Number * Name Of RTO Co Passenger Details No Of Occupants At The Time of Accident *

Relationship Of Driver *:

Applicable for commercial vehicle

Permit No * GL/LR No * Permit Valid Up To * Permit Valid For * Fitness Certificate Issuance Date * Fitness Certificate Valid Up To *

Applicable for third party property damage or injury

Name of Third Party/Occupants/Driver/Property * Contact No. * Type of Injury * Address of Hospital where Admitted * Any Legal/Court Notice Received * + Add More
Sr. No Name of Third Party Contact No Type of Injury Address of Hospital Any Legal/Court Notice Action

Police Report Lodged *

 FIR Number * Name Of Police Station *

I hereby declare having submitted the following documents *

Date
Signature(s) of Insured(s)

(Stamp, where Insured is a juristic person)

Note: Wherein the Insured/Claimant feel necessary in relation to disclosure of information, appropriately filled-up sheets may be signed off and attached to this form.

For Accident Claims

  • Proof of insurance - Policy copy
  • Copy of Registration Book, Tax Receipt (Please furnish original for verification)
  • Copy of Motor Driving License of the person driving the vehicle at the time of accident (Please furnish original for verification)
  • Police Panchnama /FIR (In case of Third-Party property damage /Death / Body Injury)
  • Estimate for repairs from the repairer where the vehicle is to be repaired
  • Repair Bills/Invoices and payment receipts after the job is completed.
  • NEFT details of insured along with Cancelled cheque / Bank Passbook.

For Theft Claims

  • Original policy document.
  • Original Registration Book/Certificate and Tax Payment Receipt.
  • All the sets of keys/Service Booklet/Warranty Card/Original Purchase Invoice.
  • Police Panchnama /FIR (In case of Third-Party property damage /Death / Body Injury)
  • Police Final Investigation Report/Non-Traceable Report.
  • Acknowledged copy of letter addressed to RTO intimating theft and informing "NON-USE"
  • Form 28, 29 and 30 signed by the insured and Form 35 signed by the financer, as the case may be, undated and blank
  • Letter of Subrogation.
  • Letter of Indemnity.
  • Consent towards agreed claim settlement value from yourself and Financer
  • NOC from the Financier if claim is to be settled in your favor.

NEFT Documents

  • Cancelled cheque showing Name and IFSC code details.
  • Bank Statement or Passbook copy

AML / KYC Documents

  • Photo identity proof
  • Pan card copy
  • Address proof
  • KYC documents as per AML/KYC rules

The list given is indicative in nature. Further additional documents may be called for depending on the nature of the claim.

DISCHARGE VOUCHER

Claim Number

I/We hereby acknowledge having received a sum of Rs. Rupees in Numbers Rupees in Words
from Raheja QBE General Insurance Company Ltd, towards full and final settlement of my/our claim upon the said company under Policy No.

Policy No. in respect of the damage caused to my/our Vehicle No. in an accident that occurred on
Date

I/We shall have no further claim on the said company post acceptance of the above mentioned amount.

Place of Accident
Insured Claimant Name *
Date *
Signature(s) of Insured(s)

(Stamp, where Insured is a juristic person)

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