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    Motor Insurance Claim Form

    Uploaded by

    Munish Wadhwa
    The document is an own damage claim form for a motor insurance policy. It requests information about the insured, vehicle, accident/loss details, and any third party injuries or property damage. The form notes that additional documentation may be required to process the claim and assess liability. It provides the claim procedure, requiring the insured to not repair the vehicle until it is inspected, submit all relevant documents, and cooperate with any additional requests for information from the insurance company.

    Copyright:

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

    Motor Insurance Claim Form

    Uploaded by

    Munish Wadhwa
    459 views2 pages
    The document is an own damage claim form for a motor insurance policy. It requests information about the insured, vehicle, accident/loss details, and any third party injuries or property damage. The form notes that additional documentation may be required to process the claim and assess liability. It provides the claim procedure, requiring the insured to not repair the vehicle until it is inspected, submit all relevant documents, and cooperate with any additional requests for information from the insurance company.

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    Motor insurance form

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    The document is an own damage claim form for a motor insurance policy. It requests information about the insured, vehicle, accident/loss details, and any third party injuries or property damage. The form notes that additional documentation may be required to process the claim and assess liability. It provides the claim procedure, requiring the insured to not repair the vehicle until it is inspected, submit all relevant documents, and cooperate with any additional requests for information from the insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    459 views2 pages

    Motor Insurance Claim Form

    Uploaded by

    Munish Wadhwa
    The document is an own damage claim form for a motor insurance policy. It requests information about the insured, vehicle, accident/loss details, and any third party injuries or property damage. The form notes that additional documentation may be required to process the claim and assess liability. It provides the claim procedure, requiring the insured to not repair the vehicle until it is inspected, submit all relevant documents, and cooperate with any additional requests for information from the insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MOTOR INSURANCE

    OWN DAMAGE CLAIM FORM


    IMPORTANT
     To ensure expedited processing, please complete all sections in CAPITAL letters. Please tick  in the relevant boxes. Please attach additional sheet(s), if required, to answer a
    question with more detail and mention the serial number of the question.  The issuance of this form is not to be taken as an admission of liability. Verification of original vehicle
    registration and driving license as well as submission of claim form duly filled and signed only by insured is a must for survey. Please provide any additional
    document/information if required. Considering ease of lling information for an own damage claim, information regarding liability towards injury/death/property damage is
    to be furnished in an additional claim form.

    Has any person died or been injured in the accident mentioned below? Yes No
    Has any property belonging to any other person been damaged in the accident mentioned below? Yes No
    If the answer to any of the above questions is 'Yes' you will need to ll up an additional third party liability claim form to declare
    information regarding injury/death/property damage.

    INSURANCE DETAILS

    Policy No./
    Cover Note No.
    Period From D D M M Y Y Y Y To D D M M Y Y Y Y
    Insured Name

    Address for
    Communication

    Pin

    Date of Birth D D M M Y Y Y Y Phone -

    Mobile GSTIN

    E-mail

    Aadhaar Number PAN Number


    PAN Number, Aadhaar Number, Mobile Number, Email are mandatory If PAN Number not available, Please provide a copy of Form 49 or Form 60 as applicable.

    Detail of other existing insurance polices covering this vehicle:_________________________________________________________

    VEHICLE DETAILS
    Registration No. Date of Registration D D M M Y Y Y Y
    Make :___________________________ Model :_________________________ Sub-model :__________________________
    Chassis No. Financier s interest if any :________________

    ACCIDENT/LOSS DETAILS
    Date of accident/loss D D M M Y Y Y Y Time of accident/loss H H - M M am/pm
    Place of accident/loss :__________________________________________________________________________________________
    Please narrate, in detail, the events leading to the accident/loss. (Do not state police report attached or as per police report )

    For what purpose was the vehicle being used at the time of accident :_____________________________________________________
    Nature and weight of goods carried at the time of accident (Applicable for goods vehicle):___________________________________
    Number of people in the vehicle at the time of accident (Relative/Friend/occupant):__________________________________________
    Was the accident reported to the Police ? Yes No If Yes, which Police Station :____________________________________
    General Diary/Crime No./ FIR No.:________________________________________________________________________________
    Page 1 of 2
    DRIVER DETAILS
    Name of the Driver
    Date of Birth D D M M Y Y Y Y
    Driving Licence No. : Expiry date D D M M Y Y Y Y

    Name/Location of
    the issuing authority
    Class of the vehicle authorised to drive :___________________________________________________________________________
    Is the driver Owner Paid Driver Others If any other person, please specify:__________________________________
    INSPECTION DETAILS
    Please do not dismantle or repair the vehicle till it is inspected by Royal Sundaram engaged Surveyor/Assessor
    When and where can the vehicle be inspected? :_________________________________________________________________
    Contact details :________________________________________________________________________________________________
    Estimated Loss :________________________________________________________________________________________________
    ADD-ON COVER CLAIM FORM
    If you have taken the cover for the below add-on cover and if you wish to claim please  appropriate box
    Depreciation Waiver Windshield Glass Return to Invoice Cover Baggage Insurance
    Aggravation Damage Spare Car Coverage Voluntary Deductible NCB Protector
    Lifetime Road Tax Key Replacement Cover
    Tyre Cover - 1 ________________ 2 ________________ 3 ________________ 4 ________________ 5 ________________
    (Tyre Sl. No.) (Tyre Sl. No.) (Tyre Sl. No.) (Tyre Sl. No.) (Tyre Sl. No.)
    Option for others If any please specify:_________________________________________________________________________

    DETAILS FOR ELECTRONIC FUND TRANSFER


    For reimbursement only (please attach a cancelled cheque of the insured for bank details to avail the facility)
    Name of Account
    Holder (as per Bank)
    I/We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. I/We agree to provide
    any further information or documents or assistance that may be required for processing my/our claim.
    Note that the contact details such as phone number and email you have provided will be updated in our system along with your policy details. We will
    reach you through this mobile number and/or email for all future communication henceforth.

    Date D D M M Y Y Y Y Place ____________________________ _________________________________


    Signature of the insured with date
    Please refer to the claim procedure for your vehicle damage (Own Damage) claims given below or logon to www.royalsundaram.in

    OWN DAMAGE CLAIMS PROCEDURE


    Please read carefully and understand the process of a motor claim. This is only a brief and not a detailed/complete process
     Claim should be intimated to us immediately with the policy particulars.
     Do not repair the vehicle before survey.
     Survey will be arranged on receipt of claim intimation and submission of detailed estimate of repairs from the repairer.
     Original Registration Certi cate (RC)/Driving Licence (DL) to be submitted to us for veri cation and return.
     Claim form duly lled and signed only by insured as named in policy schedule must be submitted to the repairer/surveyor.
     FIR to be led wherever third party injury/death/property damage is involved. Please note that you are required to ll a separate form to provide details of third
    party involvement.
     Company may ask for additional documents and/or clari cation/information, depending on the requirement of the claim.
     Cashless facility will be arranged if required documents are in order, claim is admissible and the facility is available at the place of repair.
     Based on surveyors instructions, vehicle to be produced for re-inspection on completion of repair works.
     Original bill along with satisfaction voucher for cashless claims is required for processing the claim.
     For non-cashless claims (reimbursement claims) original cash bill or invoice with cash receipt is required for processing the claim.
     A detailed theft claim process letter will be sent to your communication address (mentioned in the policy/claim form) through registered post after intimation of
    theft claim.
    For claim status enquiries, you may contact the helpline number 1860 425 0000

    Royal Sundaram General Insurance Co. Limited


    (Formerly known as Royal Sundaram Alliance Insurance Company Limited)
    Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097. Registered Office: 21, Patullos Road, Chennai - 600 002.
    Royal Sundaram IRDAI Registration No.102 | CIN:U67200TN2000PLC045611

    1860 425 0000 SMS 567675 [email protected] www.royalsundaram.in


    PR18081/JUN18/V5 Insurance is the subject matter of solicitation

    Page 2 of 2

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