iue Hew tuotn lssuRANcE coMPANY LlMlrED

Regd. & Head Office , New nd a Bu ld ng 87, lvlahaima Gandh Road. Fod Nllmbai '100
- 001

IVOTOR VEHICLE CLA'M FORI\4

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

Please answer all required questions fully

Name of tho lnsured & Address, 6'mail lD & Mobile No. Reporting Branch/Dlvisional Ofllce

N-
obilo No.

-
R No. & Dale
case other Vehicle(s) is/are involved/
e, specify vehicle No(s).:
ame oflhe complainant, who lodged the FIR:
or whal purpose was the vehicle being used at the material

FIR: Specitthe reasons for dslayed FIR or not lodging an

of other lnsulance PolicY, ifany:

rether O;;panl(s)/ Prllion ' Ride(s) Yes / No

ffi fi
*r"effi ;*&esse_;co"tactT"-l.Xo,otpassangers/other
s / were car ed al the material time of

Commercial Vehicle:
I nladen Weight: L- Weiqht ofcoods

l^;;; -
rson carried in
of Pemir I I lcoods Vehicle

dangerous / Hazardous Goods). fes / No lr.16. i#r,Oirv perio,i I

of Passengers c€nied in case of PSV I lNo. of

passengers permitted undel Permil:
the mate altims of accid6nt:

the vehicle attached with Traile(s)? Yes/No, lfYes' specify No(s)':

/ Cover note I I Pe od ol rnsurance

 OF INJURY/ DEATH TO THIRD PARIY / E'TIPLOYEES/ DAMAGE TO THIRD PARTY PROPERTY ETC.:

No of Persoos lnjured / Died :

ether any of your Wo*man gustained

ry / dsath; Ys! / No
the wages paid to lhe concerned

, lhe nalure ofdamage to TPPDi

B.: Kindly enclose a separale Sheet slating datails ofname, age, income etc. otthe person(s) injured /died.

OF THE DRIVER ON THE WHEEL, AT THE MATERIALTIME OF ACCIDENT:

& Addr6s of the Driver

ip with lnsured: Put'X' l\Ia*

Licence No.r

of MotorVehicle(s)

Authority and
, Original issuing
renewing Authorities in
order:

the Ddving Licence is /was 6uspended anylime bythe Competent Authorily / Court:

yes, give delails:

as the driver had any previous accidents in the five years, if yes

OF DAMAGE TO INSURED VEHICLE:

& whe@ lhe damaged vehicle can be inspected:

ature & Description

the Damage to the

B.: Please enclose the estimated Cost of repairs oflhe insured vehicle

/ we the above named, do heteby, to the be3t of my/ our knowledge and belief, warrant the truth
ofthe foregoing
di;;;;; ;*ry J"p;ct, and i I we have made, or in anv further-declaration, the companymay re!.'i1".I-'.:!::t :ltl:
;;;ffiil-i;li;';i;;ilillJ" or anv suppression or concealment of ract, the policvshallbe
itli"r'u-ri"niit"t"ment'
inJ attAght to recoverihercundet, in ro3p6ct of pa3t, present or further accidents shall be lorfeited'

'Signature of the lnsured

Only the insured can sign this claim form )