GENERAL teliancegeneral.co.in ASS INSURANCE 1800 3009 ‘A RELIANCE CAPITAL COMPANY Motor Claim Form (issuance of this form dows not imply acceptance ofthe lability) Al elds inthe form are mandatory Enon jant (Owner) Tobe filed in BLOCK LETTERS Policy No. Cover Note No, Policy Period From e Full Name Meshes. ‘Adress for Communication Flat Building l RoadiSteetiSector L Nearest Landmars Loe ee Le Ll Ll TalukaVilageMDisticuCity pep | pincode Ly State ‘Change ofthe contact Details] Yes, Iwish to change my contact details] There is no change in my contact detalls Please update mentioned mobile number as prmary contact details against my policy. | also hereby confirm to be contacted on the number provided above for Claim Status (Policy Renowal Phone No, Lever iiiiit MobileNo. L111 1 4 1 1 1 1 1 J Alternate Phone No. Leer iii | Atemate mobileNo Lair 1 rr a i | Email ID DOB [aya |my ml i ‘Aadhnaar(UIDAI) No. PANO: Loto td Insured Profession 1 Prvate Service C Set Employed LI Poltician C1 Retired L] student C] Government Service] House Wife Monthly Income upto £20,000 L # 20,001 to 250,000 C1 50,001 to 1,00,000 C1 £ 1,00,001 ane above ‘Any claims made in last two insurance policies [] Yes [] No Ifyes please spectty Toren Lever iiiiiid Leeder yy Dato of Registration Registration No, Date of Purchase of Vehicle, = Xue Ly ml vy viva J Ey of Trp. Rog tna Letool yy vivid Chassis No. L Engine No. J Make L J oder L | Class of Vehicle Ov Otwowneeler commercial Financiers Oves (1 No ifyes, Name of Financier Date. L 1 1 J Time L 1 | amipm_ Vehicle Speed: Police FIR No. GD Eniery avinaiom) L111 1 4 1 1 1 1 Name of Police Station Name of Garage l J Estimate of Loss Lae Garage La No. of persons traveling atthe time of accident excluding criver Description ofthe accident (Please attach a separate shest if needed) For what purpose was the vehicle being used atthe time of accident? [] Personal []ForHire of Passenger [Carriage of Goods Vehicle was plying trom to Was any third party involve in the acedent [] Yes [] No Ife, Vehicle No. and details Diagram of location of accident, position of your vehicle, cecton in which you vehicle was moving. Street name, nearest landmark/shopibuilding ‘in shase he damaged poron Senta Layout SW I ‘An 180 9001:2008 Cortied Comany IRDAI Registration No. 103. Reliance General Insurance Company Limited. Registered Office: H Block 1" Floor, Dhrub Ambani Knowledge City, Navi Mumba!-400710. Corporate Office: Relance Cente, South Wing "Foor, Of. Westem Express Highway, Santacruz East, Mumba -400 055. Corperateldentty amber Usss031#H2000PLC128300. Trade Logo dsplayed above belongs to Anl Ohubhal Aman Ventures Private Limited and used by Reliance General Insurance Company Limited under License, RGIMCOMICOMOT-2ICLNEFMIVer? 2060617Name L jl ComespondenceAdcress Ly yb Telephone Number | rr Gender: Male / Female Date of Birth Lora} ol yy Licence No, La a a Licensing Authority Lrritiririiis ‘Valid upto Set “Type of Vehicle authorised to Drive: CHV Transport «= CLMV 1. MotorCycle] Scooter Without Gear Isthe Driver’) Owner CJ Paid Driver] Any Other Person, please specity \Was the driver under the influence of aleohot Ll Yes LINo —TypectLicence: I Permanent. Learner Driver involve in any other accident in last two years. Cl Yes CINo tyes, please provide details Details required only for Commercial Vehicle Nature of oad carried at time of accident 6. R Date and No. No. of passengers carried at time of accident = L___ PermitNo, L111 1 1 1 1 J Permit valid upto Permit Issuance Date Fitness vali upto If there isa third party property damage or injury | ‘Type of FP Loss [__tniury Death Property damage _| Status of vetin [ Passenger iver Third person | ‘Additional information required for theft claim Place of theft Le i } Time notices Lair J Dateotthet Loven ol | Poivestaion = Ly apr yrriyyriiiiid FikNo Lo 11111 J Date of FIR Lora} ol vy By whom it was frst noticed and whe Time amipm Wiinesses Name & Adéross witness Contact No. L Details of person in whose possession the vehicle was a the time of theft Relationship Purpose ‘Add On's: 19 you wish to opt a claim for ad on cover if opted under the policy ves Ono Cover for Ni Depreciaton™”” 1] Motor Secure Pus") Motor Secure Premium 409] NCB Retention cover ("Easy Monthly Insialment (EM) Protection Cover, C1] Plan!-1 EM! Plan -2eMls (Plan l-3 EMis. Dota! cover Details of any other insurance covering this vehicle (Name of Insurance Company) L414 4 a yr ye yay ya | Paotey No. L J Perod ofinsurance J Bank Details for NEFT payment (For Reimbursement Claims) Name ofthe Bank Account Holéer—] MO) Mrs. (] Ms BankAccountNo: Luu ya ius | Account: Saving] Current Name ofthe Bank Lot Branch od MIGR Code (9 it MCR code number ofthe bank and ranch appoaring on te cheque esvesby obank) Lon tt a tt a | IFSC Code (11 character code appearing on yourcheque lea) L111 411 1114 J [1 tunderstana tat anyny end due onthe premium payment any payment / claims to be direct erected to my aforesaid Bank Account” “As por IROAI, is mandatory that al payments made ta the insured are only tough electronic mode porta Note: Please attach rgnlcancaled cheque anda copy of PAN car for vetication a I ene) ‘Aadhaar CardNo. (Note: Self attested Aadhaar card copy tobe submited) D1 Iwishtocotec claim reimbursement cirectyin my Bank accountlinked wth my aforementioned Aadhaar Card. understand thatthe claim amount shall Do credited rectly inmylatest Bank accountlinked wih my Aadhar Card liWe hereby declare tha the details given above are true and correc othe best of my belief and knowledge, Inthe event above information or any part ‘hereotis found incorrect, lagree tha alright unde the policy willbe forefelted. Ihave received and read the Claim Procedure ofthe insurer attached otis, Clam ormandretained twith melus.| agree to provide altonal information tthe Company required. wilindemn‘y and hold harmless the Company duet anyloss arising out of misstatementin this form, Place: Date Signature ofthe insured (U1) : RGEMO-A00-00-19-V02-12-13 (U2) : RGI-MO-A00-00-03-V01-13-14 (U3) : RGL-MO-A00-00-04-VO01-13-14 (U4) : RGEMO-A00-00-05-V01-13-14 (UB) : RGEMO-A00-00-06-V01-13-14 (U8) : RG-MO-A00-00-17-V01-14-15GENERAL teliancegeneral.co.in ASS INSURANCE 1800 3009 ‘A RELIANCE CAPITAL COMPANY Claim Procedure: Step-by-Step Guide for Claims Ronen) (Claim has to be intimated wit our Call Centre at 1800 30089 (tl free) Intimate the claim to the insurance company immediately. Delay in intimation would tantamount to a violation of policy condition. aa > Please provide your motile no. for sending SMS about your claim status from time to time. If there has bean any injury to any passengers ora head on collsion rasuling in major damages or vehicle notin @ motorable condition due to accident please report the matter to Polce and seek a spot survey immediately before shifting the vehicle ftom the accident spot Please rush the injured tothe hospital. ‘You can seok the help of our Call Contre Executives in identiying a cashless network garage" close tothe locaton of ass. Decide onthe repairer and inform us immediately once the vehicle i left at the garage Please try to produce the vehicle for inspection as early as possible asthe policy does not pay for consequentiallaggravated damages on account of delay, ‘Submit al documents ised on time fora speedier claim setlement** Keep original documents ready for verification by our loss assessor > Produce the vehicle for re-inspection after repairs if he Iss is above Rs.20,000. Submit bills and cash receipt wihin 10 days from the date of repair. > To pay the diference bill amount over and above the labily ofthe insurance compary before taking dalvery of the vehicle from our cashless netwark garage, which can be an account of depreciation, salvage, excess, Consumables oc > We suggest you to opt fr a NEFT (electronic fund transfer to your bank account direc) or Aadhaar based payment for @ hassle free claim setlement, you have not chosen to repair at our cashless network garage. > Incase of a loss due to rots inform police immediatly > loss is on account of fro, inmate fre brigade immed ately and try to minimise loss. > Incase of thet claim, repot the loss immesiately to the insurance company and also the police. Informing insurers immediately helps us co-ordinate withthe police for acing ofthe varicle through the investigator. > To co-operate withthe investgator in thet claim and provide necessary information sought by him > Ifyou would lke to lodge a claim under the personal accident cover ofthe policy for death or permanent total disablement or loss of limbs or eyes" do intimate the call contre executive of the same. “conditions ape “Clam amount shallbe subject othe poy rms and constons and hee shall be deducton for gepreciaton, excess eahage et. a lid dou n Plata go trough te ply documer ease reer Secon Ill the poly aocumen Documents to be kept ready at the time of registration of a claim » Palcy Copy » Registration Book » Driving License ‘You may nave to inform the insurer of the fllowing at the time of intimation ofa claim: > How the accident took place > “The damages suffered by the vehicle > Location ofthe accident LLacation, where the vehicle is available fr inspection Injuries to passengerserverthird partes if any [Name and partculas of driver who was driving the vehicle atthe time of accident “Trade Logo played above balongs to Ani Dhirubhai Ambani Ventures Private Liited anc used by Reliance Ganeral Insurance Company Limited under cans, DE Dé Cee) Claim No. beating Regisvaton Number Which hs been epaed to myour sattacion and we adit that th paymeat of ‘on sceaun ue repair by Ralanes General surane CorpanyLintad tte above garages nfl achare of mld clan vpn he sal company under Place ‘Signatur ofthe Insured: Date Name of Insured ty, Naw Muroa-400710. \U66603102000P.6128500. Tad Logo deplayed above belongs lo An Dhubhai Amba Vartures PrvaDocuments required for processing of a claim ey eee Ce Personal Accident ey Coy 7 z z RETRO Taro ¥ 7 ~ Beng cone Oy 7 * = Signal tate Ropar % = = Orgel Ropar els ard para ac % = = 4 [rian tet of ros ar et. zo 3 5 3) Garste Ghats orth oro Sa aaa Raha Cant Copy Wapuay—| —7 7 7 3 [ert soanvant rg aus Car ¥ % ¥ § (Gancteas ori pavnent ore pom ¥ * ¥ © [Coan documents for EMI payment for EMI protector v * * ‘Auto Loan Account No. v * x Farcaar nabs Copy z = = Vehicle Fitness Certificate Copy v vo x Pssngor ll aa eng z = = Sr = y = Car soya ana = y = RO fot Finan pte : % = rome ca ee : 4 = Past Vat eas é = Tapa Corte NTPs o Tana = z % Tt ono ie Sa pape” = = 7 rans orn eae os pea pata GODT = 7 ‘Sep requres incase of company “Orginal docoment to be prods for vereaton ofthe drive a he time of accident “= Rgpleabe for eommercel vhs oly Incase necessary nddonal docoments may be requir for processing of chim Ese You can always rack your claim status > On our website - ww.rellancegeneralco.n in the ‘Claims’ section > Through the Automated Interactive Voice Recorder System at our Call Centre or speak to our Call Centre Exacutves at 1800 3009 (oe) > SMS claimsiatus lesvarce of his voucher eet tobe taken at omission ot aby.