ES ET Pe ea ee United India Insurance Co. Ltd. :$-B, J.1Nehmu Road, Kolkats-700071 MOTOR CLAIM INTIMATION FORM (OD) eM Sererce dup tollate Basie cay, 1_| Registration Number of the vehicle as? AF F404 2_| Date & Time of Accident 4 May 2016 [3 | Place of Accident | new pone _ 4 | Under Police Station licrme: “TS 5 | Location where the vehicle can be i 1 ee : Vol swregen [denleshop 6 | I-spot survey done, Name, Address & Mobile number ofthe Spot Surveyor: | 7 No} 2203903115 Poceq4 sis a 8 [Policy Period __|uJaf2os tr 10) afoig 9. | Make & Model of the Vehicle Volzasegen fle 2 nt Manu Bea acne : 11 | IDV dinsured’s Declared value) 440 Ged] 12 | Name of the Insured = Vivek 13 | Address of the Insured |B, Cemac eae reE: Toon gt Foc |e = 14 | Phone number of the i an 15 | Mobile number of the Insured 17 | Name of the Driver at the time of ident [Vivek Sana. Driving Licence no, ofthe Driver‘ /igi-OL 2.004091 69 F 19 | Name & Address of the Workshop Valksasogen » Nellain" 700039 sured (Landline) | 033-221303F ! 5 SOFAS FG 16 | mail Id of the insured __lvi (5. Aer yahoo hone No. of the Repai number of the garag 22 | Fimail id of the gara Tass by the Garage | $7 24 | Brief description of the accidenvoceurrence(aitach airer) __|BEA, Topsia Road PS Til fabe S42r005859f qosiurseze | , if any Peat tain tefl sicle af front ged fully domegacl + From Onel Shcelel Bal Bumpo> ete UWe hereby declare that the particulars given above are correct and true to the best of myfour knowledge & belief. Place: Kolheda. Date & Time: 64h garg VisrleLinewe Signature of Insured Service Hub-Regionat Ujfice: inlaya House, * Bloor, $8.8, 5A.Netiew Raat, Rothata-7O0071