HDFC ERGO General Insurance Company Limited
Motor Insurance Claim Form
(To be filled in by the Insured Policy Holder or Insured’s Representatve duly authorized by Power and Atorney. Issuance of this claim form is not to be taken as an
admission of liability.)
Policy No. Client No.
Details of the Insured Person and Vehicle
Insured's Name
Address of Correspondence
City Pincode
Telephone No Mobile Email
PAN No. Vehicle No
Engine No. Chasis No
Details of the Driver at the time of Accident
Name
Address
City Pincode
Telephone No Email DOB
Driver is:
Owner Paid Driver Relative/Friend
Was he under infuence of liquor/drugs: Yes No Driving License No:
Issuing Authority Driving License Expiry Date
Type of Vehicles authorizedto drive (tick one):
LMV Transport Motorcycle
Details of the Accident and Damage to the Insured Vehicle
Date Time Place
Cause of Damage:
Accident Riot, Strike, Malicious Act Theft and Burglary
Flood, Storm, Tempest Fire, Explosion, Self-ignition Earthquake
Terrorism In transit
No. of Occupants Estimated Cost of Repairs
Give a short description of
the accident:
Third Party Injury/ Death or Third Party Property Damage
(To be filled in only where a third party injury/death or third party property damage has taken place)
Name:
Occupation: Is third party your employee Yes No
Address
City Pincode
Full Details of Personal Injury
Name and Address of
Hospital/Doctor attending to the
injured person
City Pincode
Full details of Property damage Has a claim notice been given to you
Yes No
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet
Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HDFC ERGO General Insurance
Company Ltd. displayed above belongs to HDFC LTD and ERGO International AG and used by HDFC ERGO General Insurance Company under license. Customer Service No : 022 6234 6234 / 0120 6234 6234 | Fax: 91
22 66383699 | [email protected] | www.hdfcergo.com. Product Code: MT/CF/0086/AUG17. UIN: IRDAN125P0005V01200203. IRDAI Reg No. 146. 1
Injury to Driver / Occupant
(To be filled in only when the driver or the occupant is injured)
Was driver or any occupant injured Yes No If yes give details
Declaration by the Insured
I/We, the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statement in every respect, and
I/We agree if I/We have made of in any further declaration the Company may require respect of the said accident, shall make any false or faudulent
statement, or any suppression or concealment, the policy shall be void and all rights to recover thereunder in respect of past or future accidents shall
be forfeited.
I/We hereby declare that, notwithstanding anything to the contrary contained anywhere above, no credit of the service tax, education cess and
secondary and higher education cess mentioned on this invoice will be availed by me/us or under, my/our instruction. The eligibility to avail such a
credit vests in HDFC ERGO General Insurance Company Ltd. and I/we do not have any intention to avail such credits.
Place:
Date: Signature
Instructions – Complete all items in the form and attach the following:
Accident Claims Registered load carrying capacity of the vehicles Copy of Lorry receipt
(Commercial Vehicle)
Copy of the Registration Book
For Accident Claims, the completed and signed claim from along with
Copy of the driving license of the person driving at the time of annexures should be given to the company’s representative at the
accident time of vehicle survey at the garage.
FIR, if accident reported to the police For other claim send the form along with the annexures to our claim
Estimate of repairs department: HDFC ERGO General Insurance Company Limited, 6th
Floor, Leela Business Park, Andheri kurla Road, Andheri (East),
KYC, AML documents Mumbai – 400 059.
Copy of the Fitness certificate of the vehicle (Commercial Vehicle) Retain a copy of the documents sent for your records. If you have any
Copy of the Road permit of the vehicle (Commercial Vehicle) claim related queries, please email us at: [email protected] or call
toll-free no: 1800-2-700-700.
HDFC ERGO General Insurance Company Limited
Satisfaction Voucher
(To be obtained from the insured, where payment is being made directly to the repairer.)
Motor Claim No. Motor Vehicle No.
I/We hereby acknowledge having received from
(Name of repairer/garage) my/our Motor Car/Vehicle/Motorcycle No. which has been repaired to my/our
satisfaction, and I/We admit that the payment of Rs. on account of such repairs by HDFC ERGO General Insurance
Company Limited is in full discharge of my/our claim upon the said company under policy no. in respect of the damage
caused to the said Motor Car/ Vehicle/Motorcycle in an accident that occurred on
Place: Date:
Address: Signature of the Insured
(Please affx offce Rubber Stamp for company-owned vehicle)
Customer Service Address : D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Email:
[email protected] | Fax: 91 22 6638 3699 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet
Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HDFC ERGO General Insurance
Company Ltd. displayed above belongs to HDFC LTD and ERGO International AG and used by HDFC ERGO General Insurance Company under license. Customer Service No : 022 6234 6234 / 0120 6234 6234 | Fax: 91
22 66383699 | [email protected] | www.hdfcergo.com. Product Code: MT/CF/0086/AUG17. UIN: IRDAN125P0005V01200203. IRDAI Reg No. 146. 2
HDFC ERGO General Insurance Company Limited
Motor Loss Voucher
(To be obtained from the insured or the Repairer to wh om payment is made)
Motor Claim No. Policy No.
Do you want us to deposit the claim payable amount directly to your bank a/c Yes No IFSC Code
If Yes. Bank Name: A/C Number:
Insured Name as per Bank Account: Signature of A/C Holder:
Received from HDFC ERGO General Insurance Company Limited the sum of Rupees (In Words)
in full and final settlement of our bills and cash memos for accident repairs to and/or theft of Attachments
In Support of Bank Details (Please tick the type of proof submitted):
Cancelled Cheque Bank Passbook Copy
E-mail Address:
Please affix
Revenue stamp
(Insured’s Name and Signature) if the amount
exceeds Rs.500/-
Place: Date:
Customer Service Address : D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Email:
[email protected] | Fax: 91 22 6638 3699 | www.hdfcergo.com
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HDFC ERGO General Insurance Company Limited
Motor Loss Voucher
(To be obtained from Bank, Financier or lessee where the vehicle is under Hypothecation or Hire Purchase)
Received this day of 20 from HDFC ERGO General Insurance Company Limited the sum of
Rupees (in words)
which I/we agree to accept in full satisfaction and discharge of all claims present or future under Please affix
Policy No. in respect of Vehicle No. Revenue stamp
which occurred on Rs.(in figures) if the amount
exceeds Rs.500/-
(No Objection Note where the Financier wants the claim to be paid directly to the vehicle Owner)
I/We hereby authorise the Insurance C ompany that the amount stated above may be paid to the hirer.
Signature of Duly Constituted Authority (Name of Financier/Bank/Company)
Address of Claimant
Customer Service Address : D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Email:
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited| from
[email protected] Fax: Sept
9114,222016 and L&T
6638 3699General Insurance Company Limited upto Sept 13, 2016). CIN : U66030MH2007PLC177117.
| www.hdfcergo.com
Registered & Corporate Office: 1st Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet
Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HDFC ERGO General Insurance
Company Ltd. displayed above belongs to HDFC LTD and ERGO International AG and used by HDFC ERGO General Insurance Company under license. Customer Service No : 022 6234 6234 / 0120 6234 6234 | Fax: 91
22 66383699 | [email protected] | www.hdfcergo.com. Product Code: MT/CF/0086/AUG17. UIN: IRDAN125P0005V01200203. IRDAI Reg No. 146. 3
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet
Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HDFC ERGO General Insurance
Company Ltd. displayed above belongs to HDFC LTD and ERGO International AG and used by HDFC ERGO General Insurance Company under license. Customer Service No : 022 6234 6234 / 0120 6234 6234 | Fax: 91
22 66383699 | [email protected] | www.hdfcergo.com. Product Code: MT/CF/0086/AUG17. UIN: IRDAN125P0005V01200203. IRDAI Reg No. 146. 4
