ena AO ee ecenst cone eC US Call our 24x7 Helpline 1800 266 7780 or SMS ‘CLAIMS’ to 5616181. Nore 1) Please koop the information handy before calling up the helpline number. 2) Tha issue of this form ie not tobe taken as an admission of liabilty by Tata AIG, {3 Pease sign on both sides of claim form. De nat lave any column unanswered. 4 Please enclose set certified copies of Regsation Cerificate and Driving License, Fitness & Permit Cerificate fby the ingured ss pplcable), 5 Also please enclose copies of police report and fre brigade report iflodged, Chaim No: Policy No: Vehicle Ne: Insured/Ciaimant Name: Email Id Address: City: Pin Mobile Tel Res Tel off Time & Dato of Accident / Occurrence Hes [Jam [7] pm. Place of Accident: Typo of Loss detais ovata: [_] Own Damage [] hid Paty [_]Boaiyriury [_] Poverty Short description of accident/incident (sketch averlaf} Driver's Name: etectve for type ofveices: (TET TIT IT ELL) — eiveee: CO) C1 Load carried at the time of accident No. of passengers carrod at tho time of accidant: LILI FIR Date: Police FIR no. ff any lodges Police Station:Insurance it Name of he Name of hid Pay’ | Adress Te otter | ,Namectte | oct | any Lagavcour Seno. | “Steypantwver | witgeronn) | ComteetNo. | ™FSsmage™ | Hoxntlwhere | scencing | Note Rec NB Pease sttach additonal shoot wih fl paris, Freese, ‘Show how the accident occurred by using this diagram Give street names, direction and location of abjects concerned EFT Mandate for Claim Payment 11 We hereby authorize Tata AIG General Insurance Co Ltd to pay the tenable claims under our insurance policies issued by Tata AIG General Insurance Co Ltd as per terms and conditions of the policies, directly to my /our below mentioned Bank Account in India 1 Payae Name Insured Name 2 Permanent Account Number (PAN) 3 Particulars of Bank Account Name of Bank Name of Branch dares GiyName NN FC Code COE errr Tipe of Account Seveos | | conan ‘Account Number 4 Payoo's email ID Please attach a cancelled cheque pertaining tothe Account furnished above Declaration: We hereby declare that the particulars given above are correct and complete [Mie agree to provide adsitional information to the Company, if required. (We the above named, do hereby, to the best of ‘mylour knowledge and belie, warrant the truth of the foregoing statement in every respect, and if Wee have made, orin any further declaration the Company may require in respect of the said accident, shali make any false or fraudulent statement, fr any suppression or concealment, the policy shall be void and all rights to recover thereunder in respect of past or future accidents shal be forfeited understand that the Company reserves the right of verification|*} of facts and documents relating to the policy and claim. pate: T] FI] CIT] Sianature of the insured! ‘Tata AIG General Insurance Company Limited. ‘4.601, 5th Floor, Building No. 4, Infinity Park, Dindoshi, Malad (East), Mumbai 400 097. subject mater ofthe salctation. For more details on isk factors, arms and cantons, paso read soles brochure carfuly before concluding a sae. Tata AIG General insurance Company Ltd. Regd Offee-15th oor, Tower, Peninsula dusiness Pak, ‘Ganpatrao Kadam Marg, Of Senapat Bapat Marg, Lower Pare, Mumba 400 013.