IFFCO-TOKIO
Muskurate Kaho
MOTOR CLAIM FORM
IFFCOTOKI0 GENERAL INSURANCECOMPANYLTD.
Regd. Office: Iffco Sadan Saket
To ntimate a claim pleasc call on Toll Frce.-1800-1035-499
1. Important Instructions
h e isslanee his fom is not lo be laken asan admission of hablit
be SIgned the Insurcdi Registered Owner) of the v ehicle. or where InsuredeRegstered (we dartner ship
1Sds. by 11 1 1 / e d signalory of such Partner ship or (Corporate Body alo1g wilh the office sCal ol the oncerned orgii/ u
Please do not anc any column manswered
facts nd Statements must he factual not mluenced or biascd n any form
d m . a g e d h r e must be parked at safe place to avoid any subscqucnt danage/loss. Ihe ompany will not be respothie
Pleasetcaud c tilly the attaehed list of documents requned for laster processing o your cla
tument pmonided by the nsurcd must be Self Altested.
2. Details of 'olicy Holder
Poiy No Cove Note : 1-1C14XCA7 MD100500 Claim No
To 27/02/2021
Petd of
lnsur hrom 28/02/2020
f he Thcd GNV Metal Industries Pvt Ltd.
e mber ome Office): 9811722930 Mobile Number: 9811722930
ofRegst ed Owner GNV Metal Industries Pvt Ltd.
C-28. Sector-6, Noida-201301
Email gnvindustries@[Link]
Date of Birth tdd nm
yyyy
3. Delails of incident (Accident /Thelt)
15/01/2021 Tme (a.m. p.m.): 06:00 PM Speed (km hr 15 km/hr
Surajpur, Greater Noida
1ucWhemcidentoccurred
Pace to which e vehicle was heading for before incident: Greater Noida CNG Station
p e for whi h vehicle was bcing used/parked at thetime ofincident: Was going for filling CNG
e d Wei l toods carmied at the ume ofl incident (Comm. Veh) IL
1 1epiled to the Poliee
t ng al tie ol icident
. e 1 d d r e o f the Poice Station NIA
1h ur'y Cr F I R No and Dale.
a l the piace where Insured vehicle is parkcd:
IFFCO-TOKIO
MuSKurate Kaho
4. Details of Vehicle
BS-4 CNG ICV GVW LT 7500
Registration No UP16GT8335 EICHER PRO 1075 Model:
Make:
12/03/2020 Date of Transfer(ifapplicable)
Dile of Ist Registration:
GOLDEN BROWN
[Link] ol Iinancier (il any) NIA olour ofVehicle
Vo E414NCLA316781
CNG Chassis No. MC2B8HRCOLA460630 ngne
5. Details of Driver
Relation with Insred
DRIVER
Ashu Raghav
KAPOORI NAGAR. ALIGARH 202001
146 TEES FUTA ROAD, GALI NO. 4, SABJI WALI PULIA,
Driving License NO UPB120180007685
Contact Number 8882162828 Gender: Male/ Female
27/12/2024
Issuing RTO UP 81 Aligarh License Expiry Date
Type:Permanentcarm
lass MCyele LMV/HGV/Transport/Non-Transport
6. Please describe how the incident ocurred
Our vehicle was driving at slow speed when the truck in the front braked suddenly. Our vehidle braked butthe front
right of the [Link] hit the truck in the front. Right headlight, right gate, front glass and right side of the front cabin was
damaged.
7. Details of Occupant /Passenger/Third Party/Property Injury
. Injur: Death Details:
. o. Name Address Phone No. in What ature o
Capacity injury
7. Third Party Vehicle/Property Details:
3. Other Insuranee
a ol theriilanee poliees mdemnilyg you oT tIe driver n repect ol above iceiudent
9. Past Clain History:
a s any
elamieported in the past on the same vehicle during curent year poliey :
IFFCO-TOKIO
MUSkutate Kaho
10. NCB Claimed
Name of the Insurer Percentage("%) of
Policy No0 Policy Policy
Policy Details NCB Claim
Inception Expiry
tument Poliey
Previous Poiicy
2PrevV1Ous Policy
Previous Poliey
1 '
ndertaking The hest ol my oI &nolcdge
andl helcl 1 ih trath o
fie inieponj d i t
rie
11
l . <do eTehy.
ne
Concement
of
CTs, (he clal hmi
liudulent slilcmet orIhere be an
supprCsion or it
11,1de i
Or
conipletv documents aloigith the l
Form and willproIde siuch sCtllement
cla
i s ul documents with this clam delay in
i C
slhall not be held responsiblc lorany
of this clam. The Conmpany
teequitemen he lulilled tor admunistrat1
[Link] ot reejuinenents including the submission of documentsas required
documents to the Company,
il and whhen require toa
preleTe
tu le 1ny addilional intormation lor which the C laim is being
to me'Is under the Poliey
n
eeee
herehy u n d s l . d . agree and
suhmit that No Claum Bonus(NCB)alloued vehicle (in ot translcr ol Na (
e o r carlier imsurcd case
the s u r e d vehicle or ny
clim e\pericnce lor 1.
Ijeel
to lhe
let iiit the o n damage
s t i b i l ndertake that the
oCTm
Soni
Accordingly | We nCe aga
Was NIlL | We tderlaKe n
UTCd teni)11pre\iOs ear poliey(s) NIL Clam histors. Further
he nsured \ehicle tor which the Clam is
prelerned is bascd on the abose Stiiahle
latita
P'oiicy al i s discreiion impse
IS ncorrecI. Ihen the company may
TCT1Nl
(NCB) unde Ihe currenl policy
he
sS olAA ling the NoClaim Bonus
S sectio11 ot policy
ma nelude forteilure of benetits on own daage
all
71TCd l n whi
Settlement
List of Documents Required for Claim
Service Centre)
(Tobesubmittedtothe Surveyor/Customer for Theft Claims
For Accident Claim Additional Documents
Original Poliey document
Prool of [Link]-Poliey Cover nole copy Tax paymciil re
of Reistration Book. Tax Receipi[Please furnish original Original Registration
Book Certiticaleand
py
loreriIatonj insurance details Policy No. insuring
Oftice
-
( ompan
Copv of NM Driving License |With original] of the person Previous
tor
iriv ing the hicle at the tume of accident period ot insurance
Purchase lnvoice and
Police Panehanama FIR(In case of Third Property All the sets of Key, Service Booklet. Orig1nal
Non RepoSsession Letter from Financie
dumuge Dcath Body Injury) Report
Istimate for repaursIrom the reparer where the vehicle is
to be Police Panchunama FIR and Final Investigation
Acknowledged copy of letter addressed to RTO Intumating thelt an
Repair [Link] payment receipts after the job is completed
making vehiele "NON-USE"
Claims Dis. harge Cum Sat1staction Voucher Signed across a F o r m 28, 2 9 a n d 3 0 signed by the insured and Form 35 signed by t h e
blank
Revenue Smp Financer, as the case may be, undated and
Documenis required by AML Guidelines Letter of Subrogation
Permit. Fit ew und Load (hallan (in case of Commerecial Consent towards agrced claim setlement salue from s u nd
inancer
hicle
NOC of Financerif claum i sto be settled in your tav our
Blank and undated Vakalatnama
Documents asrequired byAML Guidelines
Additional documents in specificelaims shall beintimated separately.
Mandate Form for Electronie Transfer of Claim Payments
lasurel Name GNU Mekel T-dusieo t Ld
hicl [Link] \o: ue 16 CT 8 335
Bank Details
[Link] 1Bi:anch
ES aA
Da a N Delh
ecount ype o238 Cuu
II SCCode YESBo 000 238 MICR Code*
o2388 16 o0000 37:
13i.. dedress DaAyog Nw Del
Please also atlach
one Blank Cancelle Cheque for NEFTRTGS Payment GNV METAL INDUSTRIES PVT. LTD.
[Link]
e NR, ISo202 (SignatfThumb impression of In&MEC[or
IFFCO-TOKIO
M u s k u fa fë [Link]
VOUCHER
CLAIM DISCHARGE CUM SATISFACTION
PVTLTD
Insured Nanme GNVME TAL INDUSTRIES
chicle Registration No UP16GT8335
Discharge Date
I am heneeforth takmu Jeln
to my complete salisfaction.
M chicle numT having bcen repaired
RANCE COMPAVY to
make payment f R»
authose IEFCO TOKIO GENERAL INSU
lhe nd my nsurer
also confirm having paid Rs
garage m respect of my
aforementioned vehicle. I
O 1he
work carried out at the garage
o fdepreenatron. policy cxcess and any additional
is in full and final settlement of my claim
t h a t this iNment being made to the alorementioned garage
ull & [Link] seticment
dIsharge tcceiptto the C ompany
in
INC
also subrogate a11y 12t T
n Tepeet of sdid lossaccident|We
hereby
dit
the ahoeloSs damagcs
GNV METAL INDUSTRIES
PVT. LTD.
Director
Signature and Stamp of Garage
Signatu Thumb impression of Insured
