(poe rty MOTOR INSURANCE C PRIVATE CAR/TWO WHE: {ISSUANCE OF THIS CLAIM FORM I$ NOT-TO BIE TAKEN AS AN ADMISSION OF LIABILITY Namecitw trend (5) AlT) [el WN Ww) [P| BJO] ufc |W] vl R/z| rome [el wth PAO MAG HAL UN|Y © volt) gitini@iWjolmWe's| 14 ole 1 6 (oo /0F Prtate 516 oy nly ely e\Wiald) [sue T]E|CIRINGIAINIA felet aie Bb Fah Cmte tinter Pene- sree [dew Emato (Pa [ajuic (uly lt § loli [cial @ [ni om Sialelsirioh pane af sete tome PAI I om (leh Jalna tale hte erata _ Reed Type: ClEsgreee wy CRG CNS Stat Highway ielelelse (ota Roe Ones == ‘Spee ate traf secant | [fe rch pect: Own Damage Tha © Patel The (pec) - The Party Ooath Tha Party inhry Tid Paty Proper Damage —C PersoralAcent Purpose for wen te veh nas beg used the neo acide! — Neroerotparcone rooting [[ [I] Anyatervetise mated a ee In coset et hye in te possession of? contac. Mele I Coes Cont Deas of persons lhe Location emai [| | an TET o_o Drom voude Used Crt Drake in Caric, gob clipfel ond _aashed yas -domaging \ePt lowes fash ike = FAR/OOR/GORWary: Yes Pelee FIR/GOR DOR Dette No poten siatonrame [| | | camewreons | tt ‘Scanned with CamScannerae Serums PLUS 310 falc otal alelalo _ wn (eteaialelsl oo 7 Ome Tmo WO H.C WO Ue are rane Py 0 nt of rota nda warn hu the gag state hve eer an oe a co rhe Company may tol soos cam nde Pokey sal be nl an vi, nl Sh recover ere unde espa! pat oe omlacacets sab reed, ie nave ataced th tof docuents wih is dan Farm andhave understood the eno roqurementt be filed er aintraton this im ae ne COREY Ratner hid tespnstie rary clay i seterent of em dio norte equreens Muding We document a erioned in he Sm ured, We Rte autorse the Carary to acces myiout ge op str son nt ames Coe. smraure f Seicharan rue (UNI SE] RAL BAIS | pate: [0 [0/3/21] 213) ot nsured/Cismant: P= Soi Clacton For Tet Claims nina Poti dcament 1. Poot of aurance - Pee Caver Note cony Ju 2 Copy of Registration Box, Tax Race | 2 Ongina Registration Book / Certicate and Tax Payment Rect [Pieter gral vertfleaton) | 3 Alle set thy Seren Sekt Waray Cars Orga Pura ce 3. Copy Motrin License othe person dking the vehi at__| 4. Poles Panchanoma FIR and Final Report Non Traceabi Report _e be of accxdent (Please furnish original for verfication) | 5. Acknowledged copy of letter addressed to RTO itimating thet and informing 4. Poles Pancha FIR “NONUSE™ 5: Estimate of repairs rom he eparer where the vehceis tobe | 6. Form 28, 29 and 30 signs by he insure and Ferm 38 sgn bye Financier repared 7. Subrogaton cum specal Power oAoney (6, Repair Bitsfnvoces and payment recipe afer the job & completed | 8. Consent wards agreed cam setemen value rom yoursel and Financier 7. Descharge Voucher 8. NOC tem the Fnancer Ica o be sete in you favour | 10. indemnity bond & ascharge voucher = Aditonal documents roqured by usif ay, wil be inimated to you as and when required ‘Scanned with CamScanner