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    Motor Claim

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    1) This document contains a motor claim form for IFFCO TOKIO GENERAL INSURANCE COMPANY LTD. It requests details about the policyholder, vehicle, driver, accident/incident, and includes sections to provide a description of the incident and details of any injured parties or damaged property. 2) The form lists important instructions for claimants, such as not leaving any columns unanswered and providing factual information. It also provides contact information for claim inquiries and lists documents required for claim processing/settlement. 3) Upon vehicle repair, the form includes a discharge voucher for claimants to sign, authorizing payment to the repair garage and acknowledging settlement of their claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Motor Claim

    Uploaded by

    [email protected]
    181 views4 pages
    1) This document contains a motor claim form for IFFCO TOKIO GENERAL INSURANCE COMPANY LTD. It requests details about the policyholder, vehicle, driver, accident/incident, and includes sections to provide a description of the incident and details of any injured parties or damaged property. 2) The form lists important instructions for claimants, such as not leaving any columns unanswered and providing factual information. It also provides contact information for claim inquiries and lists documents required for claim processing/settlement. 3) Upon vehicle repair, the form includes a discharge voucher for claimants to sign, authorizing payment to the repair garage and acknowledging settlement of their claim.

    Original Description:

    motor claim

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    1) This document contains a motor claim form for IFFCO TOKIO GENERAL INSURANCE COMPANY LTD. It requests details about the policyholder, vehicle, driver, accident/incident, and includes sections to provide a description of the incident and details of any injured parties or damaged property. 2) The form lists important instructions for claimants, such as not leaving any columns unanswered and providing factual information. It also provides contact information for claim inquiries and lists documents required for claim processing/settlement. 3) Upon vehicle repair, the form includes a discharge voucher for claimants to sign, authorizing payment to the repair garage and acknowledging settlement of their claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    181 views4 pages

    Motor Claim

    Uploaded by

    [email protected]
    1) This document contains a motor claim form for IFFCO TOKIO GENERAL INSURANCE COMPANY LTD. It requests details about the policyholder, vehicle, driver, accident/incident, and includes sections to provide a description of the incident and details of any injured parties or damaged property. 2) The form lists important instructions for claimants, such as not leaving any columns unanswered and providing factual information. It also provides contact information for claim inquiries and lists documents required for claim processing/settlement. 3) Upon vehicle repair, the form includes a discharge voucher for claimants to sign, authorizing payment to the repair garage and acknowledging settlement of their claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    MOTOR CLAIM FORM

    Retail Health Policy


    a. Individual Medishield
    b. Swasthay Kavach Policy

    IFFCO TOKIO GENERAL INSURANCE COMPANY LTD.


    Regd. Office: Iffco Sadan Saket

    Home & Family Protector


    Home Suvidha Policy
    Trade Protector Policy
    Trade Suvidha Policy
    Office & Professional
    Establishment Protector

    To Intimate a claim Please call on Toll Free : 1800 1035 499


    For Claim Details Please Contact
    Monday to Friday Between 9.30 a.m. to 6.00 p.m.
    Phone : 044-4963 2216
    E-mail : [email protected]
    IFFCO BHAVAN, Customer Service Centre,
    4th Floor, 128, Habibullah Road,
    T. Nagar, Chennai - 600 017.

    CZl TtV RPod :


    eLs Rp Ys YW
    LX 9.30 - UX 6.00 UYW
    RXT Gi : 044-4263 2216
    CUp : [email protected]
    ClL TYu, LvPUo Nov NuPo
    4Y U, 128, ApX NX,
    .SLo, Nu]-600 017.

    1.

    Important Instructions

    a.
    b.

    The issuance of this form is not to be taken as an admission of liability.


    To be signed by the Insured(Registered Owner) of the vehicle, or where Insured(Registered Owner) is a
    Partnership or Corporate Body, by an authorized signatory of such Partnership or Corporate Body along with
    the office seal of the concerned organization.
    Please do not leave any column unanswered.
    All facts and Statements must be factual not influenced or biased in any form.
    The damaged vehicle must be parked at safe place to avoid any subsequent damage/loss. The Company will
    not be responsible for the same.
    Please read carefully the attached list of documents required for faster processing of your claim.
    All documents provided by the Insured must be Self Attested.

    c.
    d.
    e.
    f.
    g.

    2. Details of Policy Holder


    Policy No/Cover Note : __________________________ Claim No : __________________________________
    Period of Insurance : From : _____________________________ To : ________________________________
    Name of the Insured :______________________________________________________________________
    Phone Number (Home/Office) : ______________________ Mobile Number : __________________________
    Name of Registered Owner :_________________________________________________________________
    Current Address :__________________________________________________________________________
    ________________________________________________________________________________________
    Email : __________________________________________________________________________________
    Gender : Male / Female
    Date of Birth : (dd/mm/yyyy): _____________________________
    3. Details of Incident (Accident / Theft)
    Date(dd/mm/yy) : ____________Time (a.m./p.m.) :___________Speed (km/hr)_________________________
    Exact Place Where incident occurred : _________________________________________________________
    Place to which the vehicle was heading for before incident :_________________________________________
    Purpose for which vehicle was being used/parked at the time of incident: ______________________________
    Nature & Weight of goods carried at the time of incident (Comm. Veh): ________________________________
    No of people traveling at time of incident : ______________________ Is it reported to the Police ? YES / NO
    Name & Address of the Police Station : _________________________________________________________
    Gen. Diary/Crime No/FIR No and Date :_________________________________________________________
    Name and Address of the place where Insured vehicle is parked : _____________________________________
    Estimated Loss Amount (Rs.) :_________________________________________________________________

    4. Details of Vehicle
    Registration No :_____________________Make : _____________________Model:______________________
    Date of 1st Registration : ______________________Date of Transfer (if applicable) :______________________
    Name of Financier (if any):_________________________________ Colour of Vehicle :____________________
    Type of Fuel :_______________ Chassis No.: _______________________Engine No.: ___________________
    5. Details of Driver
    Name :____________________________________ Relation with Insured : _____________________________
    Address :__________________________________________________________________________________
    Contact Number :__________________Gender : Male / Female

    Driving License No :__________________

    Issuing RTO :__________________________________ License Expiry Date :___________________________


    Class : MCycle / LMV / HGV / Transport / Non-Transport

    Type : Permanent / Learners

    6. Please describe how the incident occurred

    7. Details of Occupant /Passenger/Third Party/Property Injury


    7a. Injury/Death Details:
    S.
    No.

    Name

    Address

    Phone No.

    In What

    Capacity

    7b. Third Party Vehicle/Property Details:

    8. Other Insurance
    Detail of other insurance policies indemnifying you or the driver in respect of above accident:

    9. Past Claim History


    Was any claim reported in the past on the same vehicle during current year policy ?

    Nature of
    Injury

    10. NCB Claimed


    Policy Details

    Policy No

    Policy
    Inception

    Policy
    Expiry

    Name of the
    Insurer

    Percentage(%)
    of NCB Claim

    Current Policy
    1st Previous Policy
    2nd Previous Policy
    3rd Previous Policy
    Undertaking
    1.

    I/We the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing
    statements in every respect and agree that if I/We have made any false or fraudulent statement or there be any
    suppression or concealment of facts, the claim shall be forfeited.

    2.

    I/We have received a list of documents with this claim Form and will provide such complete documents along with the
    signed Claim Form and have understood all the requirement to be fulfilled for administration of this claim. The Company
    shall not be held responsible for any delay in settlement of claim due to non-fulfillment of requirements including the
    submission of documents as required.

    3.

    I/We agree to provide any additional information/documents to the Company, if and when required.

    4.

    I/We hereby understand, agree and submit that No Claim Bonus (NCB) allowed to me/us under the Policy for which the
    Claim is being preferred/lodged is subject to the fact that the own damage claim experience for the insured vehicle or
    my/our earlier insured vehicle (in case of transfer of No Claim Bonus from earlier insured vehicle) in previous year
    policy(s) was NIL. Accordingly I/We once again submit/undertake that the No Claim Bonus (NCB) allowed under the
    current year Policy for the Insured Vehicle for which the Claim is preferred is based on the above NIL Claim history.
    Further I/We undertake and submit that in case the basis of availing the No Claim Bonus (NCB) under the current policy is
    incorrect, then the company may at its discretion impose suitable damages on the preferred claim which may include
    forfeiture of all benefits on own damage section of policy.

    List of Documents Required for Claim Settlement


    (To be submitted to the Surveyor/Customer Service Centre)

    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.

    For Accident Claim


    Proof of insurance-Policy/Cover note copy
    Copy of Registration Book, Tax Receipt
    [Please furnish original for Verification]
    Copy of Motor Driving License [With original] of the
    person driving the vehicle at the time of accident
    Police Panchanama/FIR(In case of Third
    Property damage/Death/Body Injury)
    Estimate for repairs from the repairer where the
    vehicle is to be repaired
    Repair Bill and payment receipts after the job i
    completed
    Claims Discharge Cum Satisfaction Voucher
    Signed across a Revenue Stamp
    Documents as required by AML Guidelines
    Permit, Fitness and Load Challan
    (in case of Commercial Vehicle)

    10.
    11.
    12.

    Additional Documents for Theft Claims


    Original Policy document
    Original Registration Book/Certificate and
    Tax payment receipt
    Previous insurance details - Policy No, insuring
    Office / Company, period of insurance
    All the sets of Key, Service Booklet, Original Purchase
    Invoice and Non Repossession Letter from Financier
    Police Panchanama/FIR and Final
    Investigation Report
    Acknowledged copy of letter addressed to RTO
    intimating theft and making vehicle NON-USE
    Form 28, 29 and 30 signed by the insured and Form 35
    signed by the Financer, as the case may be, undated and blank
    Letter of Subrogation
    Consent towards agreed claim settlement value
    from you and financer
    NOC of Financer if claim is to be settled in your favour
    Blank and undated Vakalatnama
    Documents as required by AML Guidelines

    Additional documents in specific claims shall be intimated separately.


    Insured
    Name:
    Date &
    Place:

    (Signature/Thumb impression of Insured)

    Mandate Form for Electronic Transfer of Claim Payments


    Insured Name :
    Vehicle Registration No :
    Bank Details
    Bank Name
    Bank Branch
    Account Type
    IFSC Code*

    MICR Code*

    Account Number
    Bank Address
    *Please also attach one Blank Cancelled Cheque for NEFT/RTGS Payment
    Insured
    Name:
    Date &
    Place:

    (Signature/Thumb impression of Insured)

    CLAIM DISCHARGE CUM SATISFACTION VOUCHER


    Insured Name
    Vehicle Registration No
    Discharge Date
    My vehicle number ________________ having been repaired to my complete satisfaction, I am henceforth taking
    delivery of the same and authorise my insurer IFFCO TOKIO GENERAL INSURANCE COMPANY to make
    payment of Rs ____________ to the ________________ garage in respect of my aforementioned vehicle. I also
    confirm having paid Rs ________________ in lieu of depreciation, policy excess and any additional work carried
    out at the garage.
    I agree that this payment being made to the aforementioned garage is in full and final settlement of my claim.
    I/we hereby voluntarily give discharge receipt to the Company in Full & Final settlement of all my/our claims
    present or future arising directly/indirectly in respect of said loss/accident. I/We hereby also subrogate all my/our
    rights and remedies to the Company in respect of the above loss/damages.

    Signature/Thumb impression of Insured

    Signature and Stamp of Garage

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