INCIDENT REPORT

Insurer Ref. No. Cause of Loss

Propel Ref. No. Description Of
Zoom Ref. No. Loss
Insured Name Place of Stolen
Address FIR Date
FIR/Complaint
Contact No
Number
Email id Complaint Status
Battery Outward
Case ID
From
Battery Outward
Driver ID From our station-
Address
Battery Outward Date of
Date Investigating Visit
Battery Theft Place of
Incident Date Investigating Visit
Battery Theft
Loss Estimated
Noticed Date
Battery Theft
No. of Batteries
Incident Reported
Stolen
Date
Vehicle
Battery ID 1
Driver/Owner Name
Vehicle Driver /
Battery Sr. No. 1
Owner Contact
Vehicle Battery ID 2
Vehicle Type Battery Sr. No. 2
Brief Description of Loss:

Regd. Off: C-46, Unchepar, Mandawali, Fazalpur, Near SBI ATM, Delhi-110092 Page 1 of 2
 Steps taken after the loss:

Reason for delay in intimation (if any):

Name
Signature and Stamp
Designation
with Date
Contact No.

Regd. Off: C-46, Unchepar, Mandawali, Fazalpur, Near SBI ATM, Delhi-110092 Page 2 of 2