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6DP/M004166 Paus (osch pad 6 sheetsy2008-10

Clalm Intlmatlon
Statlon
Dale
From Time

Phone No.

To
The New India Assurance Co. Ltd.,
Claims Hub
Visakhapatnam/Vijayawada

Sir,
Ref: 1)Accident to my/our Vehicle No.
My/ our Vehicle met with an accident on kindly iseua claim forms and
insurance hereunder for further actlon.
particulars are furnished
Policy No./Covenote No.
Policy Period
Date&Time of Accident
Spot of Accident

Name of Driver

Vehicle No. / Make

Name of the Police Station

where matter has been reported

Vehicle is in the Sport

Please arrange spot survey Yes INo.

Spot Survey was arranged

by your office at Yes No.

Name of garage where

the Vehicle is kept

Estimated Amount of Loss

Yours faithfully

Insured

ForOffice Use Only

********°°****°*°°°********°*°*°* AM PM
Received on
claim form issued b y******°°*******°****°**
.. *****'** '********************°*****'***************°**********
* * * * * * * * *

Mr. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ' * * *
is deputed for Spot Final Survey.

Dy. Manager/ Manager

Claims Hub
 CHENEWINDIAASSURANCE COPANY LIMITED
Regd &tHead OfficeNewilndia Assurance Bailding-87Mahatma GandhiRoad, Mumbai 400 001
MOTOR VEHICLECEAIMFORM
THEISSUE OF THIS FORMS IS NOT BE TAKEN AS ADMISSION OF ANY LIABILITY
Please answer all required quetions fully
Date& Time of
Claim No.:
Initimation
Period of Insurance
Policy No.
Cover Note No.

Name ofthe lnsured&Aderess,emal ld &Mobile No Reporting BranchDivisionaf Office

Non Sult Clalms Hub - VIJAYAWADA (620002),

D.No. 39-10-10/1&39-10-11/A, Datta Sai Vemuri Towers,

PIN E-mail ld 3rd Floor, Vet. Hospital Road, Labbipet,
Mobile No PAN No.
VJAYAWADA 520 010.
Bank AVc Particulars
Phone: Off: 0866 -2474893
(AVC No.
IFS Code E-mail: ch6202@newindia.co.in

DETAILS OFAGCIDENTÍTET
Date Time Place

Police Station:
FIR No.& Date Charges U/s

Incase other Vehicle(S) is /are involved Policy details of that

responsible, specityvehickes No (s) Vehicle(s)

Name of the Complainant, who odged the FIR:

For what purpose was the vehicle being used at the material time ?

Brief particulars of the

accident

FIR :Specify the reasons for delayed FIR Or not lodging and FIR

Details ofofher insua Poljey

Policy No : Period Of Insurance

THE INSURED VEHICLE PARTICULARS

Year Engine No. Chasis No. Cubic/ Carying Capacity
Regd. No. Make

ForPrivate Vehicle Give nane and addresses, contact Tel. No. of passangers/others
No
Whether Occupants (s) / Pillion Riders(s) was/ Yes / witnesses it any
were carried at the material time of accident?

For Commercial.Vehiclew Kgs.

Kgs. |Unlader Weight: Kgs. Weight of Goods Carried
Regd. Laden Weight:
Type Permit Nature of Goods Person Carried in
carried Goods Vehicle
Whether Public Liability Policy is taken Yes / No fNoyes. specty Policy
(For dangerous / Hazardous Goods) & vatidity perlod

No.of Passengers camied in case of PSV No. of Passengers pemitted under Permit
at the material time of accident
Whether the vehicle attached with Trailer(s)? Yes / No, f Yes, specity No(s)
Policy/ Cover note Nos Period of insurance

DETALS OFINJUR DEATHO THIRD PARIIEMPLOYEES DAMAGETO THIRDDARIY PROPERTY ETo

Specity No. of Persons Injured/ Died Injured No Death No No

Whether any of your Workman sustained Injured No Death No No

injury death: Yes No

Specity the wages paid to the concerned

Workman/men
Specity, the nature of damage to TPPD: Approximate Cost of Rs
TPPD damage:
N.B.: Kindly enciose a separate Sheet stating details of name, age, income etc. ofthe person(s) injured/ died.

DETAILS OFHE DRIVER ON THE WHEEL AT THE MATERIALTIME OF ACclDENT

Name& Address of the Driver Age

ReLationship with Insured: Put X Mark Self Own Paid Relation/Friend/ Other
Driver
Driving Licence No. Issuing Auttority:
Specty, type(s) of Motor Vehicle(s) Date of expiry
Authorised to drive
Specity, Original issuing Authority and
subsequent renewing Authorities in
chronological order
Whether the Driving Licence is / was suspended any time by the Competent Authority/ Court Yes / No

f yes, give detaiis:

Has the driver had any previous accidents in the five years,
gve details
if yes
DETAILS OF DAMAGETO INSURED VEHICLE:
When& wherethe damaged vehidle can be inspected:

Nature&Description IDV: Rs. Approximate Estimated Rs.

of the Darnage to the Rs. Cost of repairs:
insured Vehicle

N. B.: i lease enciose the estimated Cost of repairs of the insured vehicle

|we the above named, do hereby, to the best of my our knowledge and belief, warrant the truth ofthe foregoing statements in every
respect. andl/ we have made, or in any further declaration, the Company may require in respect of the said accident, shail make any
false or fraudulent statement, or any suppression or concealment of fact, the policy shall be void and all right to recover thereunder, in
respect of past, present or further accidents shall be forteited.

Place

Date Signature of the Insured

Only the insured can sign this claim form )|

 The New India Assurance Co. Ltd
Central KYC Form for lndividual
Please fill this form in ENGLISH and in BLOCK LETTERS. Al fields marked
(") are mandatory.
Photo
1 PERSONAL DETAILS
NAME (same as in ID proof*
Father's/Spouse' Name
Mother's Name
Date of Birth: GenderM/E/I Citizenship : Indian/Others
Marital Status" Married/Unmarried/Others
Residential Status* Resident
Individual/NRI/Eoreign national/Person of Indian origin
Occupation type (Tick &Entercode:_
L2. PROOF OF IDENTITY (Pol] (Certified copy of any one is required) Occupation Code
ProofofiDSubmitted Number Expiry date Business 8-01

Passport Professional 0-01

Voter 1D Self Employed 0-02
PAN Retired 0-03

Driving Licence Housewife 0-04

UID Student 0-05
NREGA Job Card Public Sector S-01
Simplified Measures Account no- Code Private Sector S-02
GOvernment
Others (notified by Central Govt) D no. Code Sector S-03
Not
3. PROOF OF ADDRESS (POA](Certified.copy of any one is required) Categorised x-01

Proof of ID Submitted Number Expiry date

Passport
Voter ID
Driving Licence
|UID
NREGA Job Card_
Simplified Measures AccountID no Code
Others (notified by Central Govt) |1D no. Code
3.1 Permanent Address*
Address Details:

Pincode
3.2 Correspondence Address/Local Address details*
Address Details:

Pincode
4. Contact Details
Tel (off) Tel (Res): Fax
Mobile: Email:
5. Applicant Declaration
Ihereby declare that the details furnished above are true and correct to the best of
my knowledge and belief and I undertake to inform you of any
changes therein, immediately, In case any of the above Information Is found to be false or untrue or
that I may be held liable for it. misleading or
misrepresenting. I am aware

I hereby consent to receiving information from Central KYC

Reglstry through SMS/Emall on the above registered number/email address.
Date:
Place:
Signatiure/\hunmb mpressIOn of Appicant
6. Attestation/For office use only
Officer's Name/SR No/Designation/Branch
KYC Verification carried out by
Received self attested copies
 THE NEW INDIA ASSURANCE COMPANY LIMITED
NATIONAL ELECTRONIC FUNDs TRANSFER-MANDATE FORM
TO
THE NEW INDIA ASSURANCE COMPANY LIMTED,
VWAYAWADA OD CLAIMS HUB (620002)
Olo. D.O. 1 (620700), Dr.No.39-10-10/1&39-10-11/A, 3rd Floor, Datta Sai Vemuri Towers,
Road, Labbipet, VIIAYAWADA-520 010, AP
Veterinary Hospital
NEFT
Sub: Receipt of payment through
I am giving below the details of my Bank Account for receiving policy payment
through NEFT.

01. Policy No./s. I

Name of Policy Holder / Claimant:

02. Bank Name:

03. Bank Branch Address:

04. Account Type : Savings / Current/ Cash Credit / NRI

05. Account No.

(Bank account number should be written from left to right)

06. IFS CODE:

07. Mobile No.

91 O
08. E.Mail ID

I have enclosed the following document to this effect. (Please appropriate item)

A.Cancelled cheque leaf

B. If cheque is not having the name of bank holder then Photo copy of the
page of Bank Pass Book containing details of Bank accounts number, IFS code

Signature of the Policy Holder Date

(In case of change in Bank details, please fill this mandate form again and submit
the same to our Branch Office).

Kiron/09.2020