MOTOR CLAIM FORM

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

a. The claim form is to be duly filled and signed by the insured.
b. All facts and statements must be factual not influenced or biased in any favour.
c. The damaged vehicle shall not be left unattended without proper precaution being taken to prevent further damage.
Policy Number Vehicle Number MH 12 RY 0182 Claim Number

Insured Details
Name Liladhar Pandurang Rozatkar
Address Shilpa soc. C-705, behind MIT college, paud road, Kothrud,
Pune- 411038 City Pune
State 411038
Pin-code

Mobile +918482800413 Landline Email [email protected]

* Please note that claim cheque (if any) will be dispatched to the address mentioned above. This address will be updated in above mentioned policy.

Name (As per Bank Account)

Bank Details - Bank Name Branch

Type of A/c A/c No PAN No.

IFSC Code MICR Aadhar No.

Loss Details

Date & Time of Accident D D M M Y Y Y Y H H S S am/pm

Place of Accident

Types of Loss: Own Damage Theft *Third Party

Place of Accident Bhigwan, Pune, Maharastra, India

Police Report Details, if any

Driver Details at the time of Accident

Name Age

Driver License No. Name of RTO Learners License Yes No

Co passenger details

Applicable for Commercial Vehicle

No. of Passengers carried at the time of Accident G R Number & Date

Permit No. Permit Issuing Authority

Permit Valid up to Permit valid for (Area)

Fitness Granting Authority Fitness valid up to

Applicable for third party property damage or injury

Name of Third Party/Occupants/Driver/Property Contact No Type of Injury/Property Damage Name of the Hospital where admitted Any Legal/Court Notice Received

I hereby declare having submitted the following documents

Copy of Policy/Cover Note Copy of RC Book Copy of Driving License Estimate of Repairs Copy of Fitness Certificate Copy of Permit

Copy of FIR G. R. Form

DECLARATION:

I/We here by declare that the details given above are true and correct to the best of my belief and knowledge .In event above information or any part thereof is found incorrect, I/We agree that all rights under
the policy will be forfeited. I/We also agree to provide additional information to the company, if required.

Date D D M M Y Y Y Y

Insured Signature
CFMT03_Ver_04

Future Generali India Insurance Company Limited (IRDAI Regn. No. 132), (CIN: U66030MH2006PLC165287)
Regd. and Corp. Office: Indiabulls Finance Centre, Tower 3, 6th Floor, Senapati Bapat Marg, Elphinstone, Mumbai – 400013. Website: https://general.futuregenerali.in | Email:
[email protected] | Call us at: 1800-220-233 / 1860-500-3333 / 022-67837800 | Fax No: 022 4097 6900. Trade Logo displayed above belongs to M/S Assicurazioni Generali -
Societa Per Azioni and used by Future Generali India Insurance Co Ltd. under license. Insurance is the subject matter of solicitation.
List of Documents Required

Claim Intimation Addition Documents For Commercial Vehicle

Policy Copy Fitness Certificate
Claim form Copy of FIR
Copy of RC book Permit
Copy of Driving License Load Challan
Estimate
Photos
Survey Report
Survey Fees Bills
Supplementary Report / Re-inspection report
Final repair invoice and receipt / Satisfaction voucher for cashless payment

Theft Claims

Claim Intimation
Original Policy
Claim form
Original Registration certificate
FIR
Original set of keys
Original Sales invoice & Tax receipt
Intimation to RTO (to inform RTO that the vehicle is stolen and not to transfer)
Final Report
Transfer papers
Indemnity Bond
Subrogation letter

NEFT Payment

Cancelled Cheque for NEFT Payment

AML Documents - for claims above One Lakh Rupees

Photo Identity Proof

Passport size photo – (Individual) – Mandatory
Pan card - Mandatory
Passport / Driving License / voters ID Card
Proof of Address – (last six month)
Telephone Bill / Electricity Bill / Bank Statement / Ration Card
Memorandum of understanding / Registration of Company –
Regd. Company / firm / establishment)

The list given is indicative in nature. Further additional documents may be called for depending on the nature of the claim.
CFMT03_Ver_04

Future Generali India Insurance Company Limited (IRDAI Regn. No. 132), (CIN: U66030MH2006PLC165287)
Regd. and Corp. Office: Indiabulls Finance Centre, Tower 3, 6th Floor, Senapati Bapat Marg, Elphinstone, Mumbai – 400013. Website: https://general.futuregenerali.in | Email:
[email protected] | Call us at: 1800-220-233 / 1860-500-3333 / 022-67837800 | Fax No: 022 4097 6900. Trade Logo displayed above belongs to M/S Assicurazioni Generali -
Societa Per Azioni and used by Future Generali India Insurance Co Ltd. under license. Insurance is the subject matter of solicitation.