CHOLAMA]\IDALAM MS GEI\IEMI, INST,]RANCE COMPAIIY LTD.

Regd. & Head Office : "Dare House" , 2nd Floor, No, 2, NSC Bose Road, Chennai - 600 001'
Tel :91-44-3044 5400 Fax :9t-44-3044 5550 Toll Free : 1800 200 55 44 cholainsurance.com
<P CholaGvts
Email : customercare@cholams.murugappa.com

MOTOR INSURANCE CLAIM FORM

(The issuance of this form does not imply admission of liability)

Policy/Cover Note No: ' I i i i , i : i I i i i : i i ; t ict.i'r'to'

Policy Period From i : : j i ' i i ,re: i : i j i i i inegion

lnsured Details i. Mn ,,,,,: ::14fg1, ,,,ilVls. : ., Df,: :OtherS

First Name Middle Name Last Name

Name, ii i i i ii i i i i i i i: : : i i : i : j

!- Dateof Birthi.:,i. 1,',,..1r.,;

ri.. t:_:j Gender! V.t. !remale lMaritalstatus ! Single! tvtarried I Others

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occupation! salaried I SeF-Employ.dI others Aadhar No
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Door/Flattlo: i_i j_j_: BuildingNo/Name:,, i j i j

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Street Name : !i Landmark
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Sub Area/Village: i
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Door /Flat No : i
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Sub Area/Village: : i i j ; : j i Area/rehsil j

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Vehicle Details

Enginet'to:i i : i ; i i i i i i i ; i i i i i i i : i
Make: iii,iiiiiiiii
chassisrrro:i : i j i j i i i j i i i i i i i j i i i j Model: iliiiiriiiiii
FCNo&Varidity: i : ; i i i i i i i i i i i i i i i
j j : j i j ,r i j i i : j , j i'
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LRNoandDate: i i - j

Financialtnterestifany: i .: , i i j ,: : i ,; --i i-i i l

Loss Details (Please do not dismantle the vehicle till is is subject to a detailed survey)

Date of r.oss: I ; : ; i : i i i j rimeofLoss: i i i I i I i j i j murler',r

crace or Loss: i i i . i i i i i i i I j i i i i i-i i j s,".",1 i i j i i ,i l i i i l li j

No of Person travelling in the vehicle: Occupants Fare paying Passengers:

For what purpose was the vehicle being used at the time of Accident:

Nature and Weight of the Goods Carried(for Goods Carrying Vehicles):

Travelling from:

Any Third Party was involved in the Accident:

Was the Accidentfiheft Reported to Police: Yes / No

Name of the Police Station: CR Dairy No:

Description of the Accide

Page 1 of4
Claim on Add on Covers under Chola protect

S. ilo. Name of the ltem ModefSerial No/Dt Number llssulng Authonty] Vblues in Rs.

Garage Name: phone:

Estimated Loss: Date & time of vehicle left to Garage:

Driver Detalls
, i i . i ! : i
Nameof j*-i* i*.-;*-;--*j-._i
theDriver:i*"r*..; i i ii - -i-_i....
i , _ !.-._i. i : _;*.
i : ii *r**i i jDateof
i_ BirthandAge: irf*fL**::J
l"_p"i;:_l

e|ssuingAuthority:liiiiiiiiiiii..jo,."ofExpir:
Type of Vehicle Authorised to Drive: MotorCycte / LMV(NT) lH:N l3W(W)/ XeV/ UeV/ LMV(T)/Auto
whether the Driver is: owner / paid Driver
/ Relative / Friend specify:

lnjury to Third Pafi/Occupants/Driver

Name Address Naturc of Infury Rh t{o. Whether lhld Party/Occupant/Drfver

Detalls of Thid Party Damage:

Other lnsurance Details:

ls there any other insurance policy indemnifying you in respect of this accident/theft: Yes / No
lf yes, Policy No Name of the Company/Office:

l/We hereby decl.E that the abor€ panlculars are tru! and con ct In each and a,.ry aspcct. I agrce to pro/lde any funhar Intotmadon/docu.n€ntyasdrt nc.
that may be requi.ed fo. processint my/our claims. In case ot any Information fumish€d by me/reprEentativ. ls iound inconEc! w. ag|"€ to accept th.
d.cision of company on admlsslblllw of the clalm.

Data:

Place:
Signatu,e of th. ln5u.rd with Seal

l/we hereby authorize Cholamandalam MS General Insurance Co Ltd to transfer the claim amount payable under Claim No.
to my bank account no. . with bank in
branch, Locatedat City.The M|CRCode is and the IFSC Code is
Account Type:

Date:
Place: Signature of the Insured with Seal

Documents Enclosed (For Office Use Only)

Claim Form Submitted I Verified Permit Submitted I Verifled

RC Copy Submitted I Verified Tripsheet/Load Challan Submitted I Verified

DL Copy Submifted I Verified Policy Copy Submitted I Verified

FIR Submitted I Verified FC Submitted I Verified

Repair Estimate Submitted I Verified Invoice Submitted I Verified

Page2of4
Discharge Voucher Please return this receipt duly stamped and signed to enable the company to make payment

Received a sum of Rs. towards full and final settlement of the claim no . The liability has been explained to me.

Signature of the Repairer with Seal

CHOIAMANDAIAM MS GENERAT INSURANCE COMPANY TIMITED

Registered and Head Office: Dare House,2nd Floor, No.2, N.S.C. Bose Road,
Chennai - 600 001.
Sg'st**.*s
List of Documents required for claim settlement
(To be submitted to the nearby Cholamandalam MS office / Surveyor / Repairer)

Clalm for acddental damages:

1. Proof of insurance - Policy / Covemote copy
2. Copy of Registration Book, Tax Receipt lPlease furnish original for verification]
3. Copy of Motor Driving Licence [with original] of the person driving the vehicle at the material time
4. Police Panchanama/FlR ( ln case of Third Party property damage /Death I BodV Injury/Major Loss Claims)
5. Estimate for repairs from the garage where the vehicle is to be repaired
5. Repair Bills and payment receipts after the job is completed
7. C.ancelled chq leaf for NEFT transfer
8. Please sign the attached discharge voucher after confirmation of the final claim amount.

Page 3 of 4

For assistance Please Call us at our Toll Free No: 1 8(n 200 55 44
Satisfaction Voucher Please return this receipt duly stamped and signed to enable the company to make payment

"We hereby confirm that Veh.No- has been repaired to my satisfaction and herbyfully dlscha4€ Cholamandalam General Insurance Company Ltd., fiorn
all laibilities underthis claim.l/ We also agree to pay nry share ofloss,lfany, directly to the repairer where cashless has been availed."

Signature of the Claimant

With seal if it
is company name)

CHOIAMANDA1AM MS GENERAL INSURANCE COMPANY TIMITED

Registered and Head Office: Dare House,2nd Floor, No.2, N.S.C. Bose Road, <> CholaOvts
Chennai - 500 001. GENERAL INSURANCE

List of Documents required for claim settlement

(To be submitted to the nearby Cholamandalam MS office / Surveyor / Repairer)

Claim for accidental damages:

1. Original Policy document
2. Original Registration Book/Certificate and Tax Payment Receipt
3. Previous insurance details - Policy No, insuring Office/Company, period of insurance
4. All the sets of keys/Service Booklet/Warranty Card
5. Police Panchanama/ FIR and Final Investigation Report
6. Acknowledged copy of letter addressed to RTO intimating theft and making vehicle "NON-USEU
7. Form 28,29 and 30 signed by the insured and Form 35 signed by the Financer, as the case may be, undated and blank
8. Letter of Subrogation
9. Consent towards agreed claim settlement value from you and Financer
10. NOC of the Financer if claim is to be settled in your favour
11. Blank and undated "Vakalatnama"
12. Cancelled Chq leaf for NEFT
13. Please sign the attached discharge voucher after compensation of the final claim amount.
Additional documents in specific claims shall be intimated separately.

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For assistance Please Call us at our Toll Free No: 1 800 200 55 44