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Motor_OD_Claim_Form (1)

Motor_OD_Claim_Form (1)

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servicebwr
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97 views1 page

Motor_OD_Claim_Form (1)

Motor_OD_Claim_Form (1)

Uploaded by

servicebwr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UNITED INDIA INSURANCE COMPANY LIMITED

Registered & Head Office, 24 - Whites Road, Chennai - 600 014.


Motor OD Claim Form
The issue of this form is not to be taken as Admission of Liability

Policy No. 2908003123P109092790


InsuredDetails: Insured Name : MR DHEERAJ GURJAR
Insured Address: S/O RAM LAL GURJAR, R/O BRIKCHIYAWAS, DT - AJMER, RAJ

Pin Code: 305203 State: RAJASTHAN


Mobile:8306635096 E-Mail:
Aadhar No: 4659-5838-4699 PAN No: DJWPG8133C
Bank Account No: Bank Name:
Account IFSC Code No: Branch Name:
Details:
Vehicle Details: Registration No: NL01AH2961 Make: 2023 Model:NA5525N/34 TTCC
Engine No. PFPZ507572 Chassis No. MB1T2VLD6PPEX9234
Date & Place Date of Loss: Time: A.M. / P.M.
of Loss: Place of Accident / Theft:

Driver details: Driver Name: SORAJ GURJAR


Driving Licence No / Expiry Date: RJ4820210000062
Accident
Details :
Provide brief
description
No of Occupants carried: 02
Workshop Details: Name & Address of Workshop: SANDEEP TRUCKS PVT LTD BEAWAR

Workshop Mobile: +91 88755 11218 Email:[email protected] Estimate Amount: Rs.


Theft Claim: Theft of Vehicle: Yes / No Details : NO

Theft of Accessories: Yes / No Details : NO

FIR Details: Accident/Theft reported to police: Yes/No Name of Police Station: NO


Date of reporting to Police: NO FIR/Crime diary number: NO
Third Party Any Injury/Death to Driver: Yes/No Details: NO
Loss Details
Any TP Injury/Death: Yes/No Details: NO

Any Injury/Death to Occupant: Yes/No Details: NO

Any TP Property Damage: Yes/No Details: NO

DECLARATION BY THE INSURED


I/We the above named, do hereby, to the best of my / our knowledge and belief, warrant, the truth of the foregoing statement in every
respect, and I / We agree that I / We have made, or in any further declaration the company may require in respect of the said
accident, shall make any false or fraudulent statement, or any suppression or concealment the policy shall be void and all rights to
recover thereunderin respect of past or future accidents shall be forfeited.
Date:
Place: Signature of Insured / Claimant

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