COMMERCIAL VEHICLE INSURANCE POLICY TRAILER CLAIM FORM ISSUE OF THIS CLAIM FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
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1 COMMERCIAL VEHICLE INSURANCE POLICY TRAILER CLAIM FORM ISSUE OF THIS CLAIM FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY If any detail or information Is not readily available please do not delay the dispatch of this form and other particulars may be sent later Policy Number Period of Insurance to Claim Number A. DETAILS OF INSURED/CLAIMANT Name as per Policy Contact Details City State Pin Code Phone Number Mobile Number ID Limits of Indemnity under the Policy/IDV (Rs.) B. DETAILS OF LOSS/DAMAGE /ACCIDENT Date of Loss/Damage/ Accident / / Time of Loss A.M. / P.M. Location City State Pin Code Contact Details of person/s at Location Name Relationship with Insured Phone Number Mobile Number ID Describe Cause of Loss/Damage/ Accident (Sketch the accident using diagram on Page 4 of the form) Estimated Loss (Rs.) Page 1 of 5
2 WITNESS DETAILS Were there any witnesses to the loss /Damage/ accident? (Yes) (No), If Yes, Person/s City State Pin Code Phone Number Mobile Number ID INFORMATION TO AUTHORITY Has the loss been reported to an Authority (Yes) (No), If No, reason for not reporting If Yes, provide details Fire Police Municipality Other Authority Information Report No./Authority Reference No. and Date Contact Person/s City State Pin Code Phone Number Mobile Number ID C. VEHICLE DETAILS Reg. No. Make Model Chassis No. Engine No. VIN No., Date of Registration / / RTO Jurisdiction Date of transfer / / RTO Jurisdiction Type of Fuel Colour of Vehicle Vehicle Class Two Wheeler Pvt. Car Commercial Miscellaneous Others(specify) D. DETAILS OF OTHER INSURANCE Is the loss/damage covered under any other Insurance (Yes) (No), If Yes, specify details and attach a copy of the policy Insurer: Policy No. Period of Insurance to Sum Insured (Rs.) Page 2 of 5
3 E. DETAILS OF OTHER INTEREST Is the Insured the Sole Owner of the property? (Yes) (No), If No, specify Nature of Interest Person/s who has/have interest on property _ F. DRIVER DETAILS Driver Relationship with Insured Gender Male Female Date of Birth / / Driving License No. Date of Issue / / Date of Expiry / / Issuing RTO Type of License Permanent Temporary Class M-Cycle W/G M-Cycle Wo/G LMV Transport Non-Transport HGV Passenger Goods Special Endorsements, if any G. ACCIDENT/THEFT DETAILS Speed at the time of accident kmph. Type of Loss Own Damage Theft Partial Theft Others (specify) Third Party Death Third Party Injury Third Party Property Damage Personal Accident Purpose for which the vehicle was being used at the time of accident/theft No. of people travelling in the vehicle at the time of accident Weighment Details RLW ULW GVW Weight Carried In case of theft, keys in the possession of? Name Contact No. Page 3 of 5
4 H. GARAGE/BODYSHOP/REPAIRER DETAILS Name Contact person I. THIRD PARTY DEATH/INJURY/PERSONAL ACCIDENT DETAILS(Attach additional sheet, if required) Sl. No. person Whether TP Passenger Contact No. Death/Type of Injury Hospital where admitted Attending Doctor Details of Any Legal/Court Notice received J. DIAGRAM K. DETAILS OF PREVIOUS LOSSES Losses during the 3 preceding years Date of Loss Claim Description and Cause of Loss Value of Loss (Rs.) Insurer L. DETAILS OF OTHER INFORMATION Do you wish to provide any other information? (Yes) (No), If Yes, specify Page 4 of 5
5 DECLARATION 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 I/we agree that if I/We have made, or in any further declaration, the Company may require in respect of the said accident, shall make any false or fraudulent statement, or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and void, and all rights to recover there under in respect of past or future loss/accidents shall be forfeited. I/We have received a list of documents with this claim Form and have understood the entire requirement to be fulfilled for administration of this claim and the Company shall not be held responsible for any delay in settlement of claim due to non-fulfilment of requirements including the documents as mentioned in the claim form. I/We agree to provide additional information and additional documentation to the Company, if required. Place Date Signature Insured/Claimant LIST OF DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT * For Accident/Theft Claims 1. Proof of insurance - Policy / Cover note copy 2. Copy of Registration Book, Tax Receipt [Please furnish original for verification] 3. Copy of Motor Driving License of the person driving the vehicle at the time of accident (Please furnish original for verification) 4. Police Panchanama /FIR ( In case of Third Party property damage /Death / Body Injury) 5. Estimate for repairs from the repairer where the vehicle is to be repaired 6. Repair Bills/Invoices and payment receipts after the job is completed Additional documents for Theft Claims 1. Original Policy document 2. Original Registration Book/Certificate and Tax Payment Receipt 3. All the sets of keys/service Booklet/Warranty Card/Original Purchase Invoice. 4. Police Panchanama/ FIR and Final Investigation Report/Non Traceable Report. 5. Acknowledged copy of letter addressed to RTO intimating theft and informing "NON-USE" 6. Form 28, 29 and 30 signed by the insured and Form 35 signed by the Financer, as the case may be, undated and blank 7. Letter of Subrogation 8. Consent towards agreed claim settlement value from yourself and Financer 9. NOC from the Financer if claim is to be settled in your favour. Additional documents required by us if any, will be intimated to you as and when required Tear here DISCHARGE VOUCHER Claim No. I/We hereby acknowledge having received a sum of Rs. /- Rupees ( ) from SBI General Insurance Company Ltd. towards full and final settlement of my/our claim upon the said company under Policy No. in respect of the damage caused to my/our Vehicle No. in an accident that occurred on / / (DD/MM/YYYY) Place Date Signature Insured/Claimant Page 5 of 5
B. DETAILS OF ACCIDENT:
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Health Insurance Ab Health Hamesha Claim Form - ASSURE Part A 1. To be filled in by the Insured. 2. The issue of this Form is not to be taken as an admission of liability. 3. To be filled in block letters.