Kotak Car Secure (Comprehensive Policy)
VEHICLE INSURANCE CLAIM FORM
For claim intimation please call on our Toll Free Number 18002664545
GUIDELINES FOR COMPLETION OF THE CLAIM FORM
1. Claim form is to be filled in BOLD AND BLACK INK; filled & signed by the Insured. Fields marked * are MANDATORY
2. Please do not leave any column unanswered
3. Please provide complete information in respect to all details sought under this claim and ensure that all details are completed truthfully and accurately
4. All facts and statements must be factual not influenced or biased in any form.
5. Please read carefully the attached list of documents required to speed up processing of your claim.
The issue of this form is not to be taken as an admission of the Company's liability
TYPE 0F LOSS
Loss Type* Own Damage Third Party Personal Accident
INSURED DETAILS
*Policy / Cover Note # 3105644000 Claim#: 10110158820
Name*: M JOHN UTTAR
Address*:
Address(Line 1): JAIN PEBBLE BROOK, BLOCK 3 TP, SAKTHI GARDEN. OKKIYAM THORIPAKKAM CHENNAI 600097
Address (Line 2) Nearest Landmark
City/District : CHENNAI State: TAMIL NADU Pincode : 600097
Country: India
Mobile 8072368367 Email:
[email protected]INSURED VEHICLE DETAILS:
*Date of Registration 06/04/2015 *Registration Number : TN07CB5919
Engine Number G4LAFM632521
*Chassis Number MALA851CMFM264959
*Make Of Vehicle HYUNDAI MOTORS Model: GRAND I10 ASTA 1.2 (O)
Odometer Reading Kms
*DETAILS ABOUT THE DRIVER / RIDER (AT THE TIME OF ACCIDENT)
Name*: K M Balaji
Gender Date Of Brith:
*Driving License Number :
*License Issuing Authority: *License Date Of Expiry :
TN04X20000000551
*License for type of Vehicle Was the License temporary? Yes No
If paid driver, how long has he been in your employment?:
Relation with Insured
_____yrs
Was he under the influence of intoxicating liquor or drugs? Yes No
Details of endorsements, suspension if any
DETAILS OF ACCIDENT
*Date : 14/04/2023 *Time: 18:07 Speed Of Vehicle: Kmph No of occupants:
Pillion rider
Exact Location of Accident (Address / Spot of Accident with landmark) : 600041 TIRUVANMIYUR
Give Brief Description of the Accident: While swimming I lost my key in beach
Was accident reported to Police : Yes No If not, reasons
If yes furnish the details: Name of the Police station : FIR No. / CR Dairy Number:
For Commercial Vehicle :
Permit Valid Upto: Load carried at Time of Accident: Fitness valid upto:
DETAILS OF GARAGE
Garage Name Garage Phone Number:
Garage Contact Person And Address :
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai 400097. India.
Toll Free: 1800 266 4545 Email:
[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
OCCUPANT / PASSENGER / THIRD PARTY INJURY DETAILS / PILLION RIDER
S.No Name Address Phone No Capacity Nature of Injury
1
2
3
4
PARTIAL/TOTAL THEFT
Brief description of third party property damage (include other vehicle involved) :
Date : Time: AM/PM Place Of Theft:
Circumstances relating to theft Items stolen (for partial theft)
Estimated cost of replacement (for partial theft claims)
By whom discovered and reported
Has theft been reported to Police Yes No If not, reasons
When (date & Time) A.M/P.M Name of the Police station :
FIR No. / CR Dairy Number :
Name of attending inspector
CONSENT FOR FUND TRANSFER FOR CLAIM PAYMENT (FOR REIMBURSEMENT CLAIMS)
Mandatory details required to process all payment due in relation to your policy including refunds (if any) and or claims directly to your bank accounts. Please
select any one of the below options as applicable.
Bank details as per premium cheque to be used for electronic fund transfer
Cancelled Cheque submitted of other bank
Particulars of bank account: Bank Name
|_____________________________________________________________________________________|
Account Number |__________________________________________|
IFSC/MICR Code |_________________________________________|
Account Holder name |_______________________________________________________________________________|
Disclaimer: Kotak Mahindra General Insurance Company Limited shall not be liable to anybody, in any manner, whatsoever if the NEFT transaction does not
complete
DECLARATION:
I / We hereby declare that the statements made by me / us in this Claim Form are true to the best of my / our knowledge and belief
Place: ___________________________
*Date________________________ *Signature / Thumb Impression of Insured
DOCUMENTS REQUIRED
For Accident Claims For Theft Claims For Third Party Claims For Personal Accident Claims
Claim Form Duly Signed* Claim Form Duly Signed* Claim Form Duly Signed* Claim Form Duly Signed*
R. C. **Copy of the Vehicle R. C. **Copy of the Vehicle R. C. **Copy of the Vehicle R. C. **Copy of the Vehicle
Driving License Copy** Driving License Copy** Driving License Copy** Driving License Copy**
Policy Copy - (First 2 Pages Policy Copy - (First 2 Pages Policy Copy - (First 2 Pages Policy Copy - (First 2 Pages
only) only) only) only)
FIR Copy/ Panchnama/ Policy
FIR Copy, Untrace Report,
FIR Copy FIR Copy inquest report duly attested by police
Dumping Yard Certificate
station
NOC from Finance Company (If Copy of Medico Legal Certificate
Estimate of repairs MACT / Legal Notice duly attested by the concerned
Hypothecated)
Hospital
Original Repair Invoice, Payment Letter of Indemnity and Documents as required by AML
Documents as required by AML
Receipt Subrogation* Guide Line
Letter of Indemnity and Documents as required by AML
Subrogation* Guide Line KYC
Documents as required by AML
KYC For Accidental Death Claim:
Guide Line
KYC Previous Insurance details Original Death Certificate
Acknowledged copy of letter Death Summary issued by
For Commercial Vehicle addressed to RTO intimating theft and Hospital
making vehicle “NON USE” Post Mortem Report (if
conducted)
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai 400097. India.
Toll Free: 1800 266 4545 Email:
[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
Form 28, 29 , 30 signed by the
insured and form 35 signed by the Identity proof of Nominee or
Certificate of Fitness Original Succession Certificate/
financer, as the case maybe undated
and blank Original Legal Heir Certificate
Consent towards agreed claim
Copy of Permit For Disablement Claim:
settlement value from you and financer
For Accident Claims For Theft Claims For Third Party Claims For Personal Accident Claims
Blank and Undated Treating Medical Practitioner’s
“Vakalatnama” certificate describing the disablement;
**
Discharge summary from the
Hospital **
Photograph of the Insured Person
reflecting the disablement
Prescriptions and consultation
papers of the treatment;
Disability certificate issued by
treating Medical Practitioner.
Any other medical, investigation
reports, inpatient or consultation
treatment papers, as applicable
*Stamp required in case of company **Original Documents to be produced for verification.
Claim No. : 10110158820
VEHICLE REPAIR SATISFACTION VOUCHER (FOR CASHLESS SETTLEMENT)
I/ We hereby acknowledge having received from___________________ garage my/our vehicle HYUNDAI MOTORS Make &
Model GRAND I10 ASTA 1.2 (O) bearing Registration Number _________________ Which has been repaired to my/our
satisfaction and I/we admit that the payment of INR______ on account of such repair by Kotak Mahindra General Insurance Company
Limited to the above garage is in full discharge of my/our claim upon the said company under Policy No. 3105644000 in respect of
the damage caused to the above mentioned vehicle in an accident which occurred on_____
Place: ___________________________
*Date________________________ *Signature / Thumb Impression of Insured
CLAIM DISCHARGE VOUCHER (#) (FOR REIMBURSEMENT CLAIMS)
Claims No 10110158820 Date of Loss:14/04/2023
In consideration of approval of my /our claim, I /we hereby accept from Kotak Mahindra General I nsurance Company Limited the sum
of INR________________ Rupees (amount in words) _____________________________________________ in full and final
settlement of my/our claim. I / we hereby voluntarily give discharge receipt to the company in full and final settlement of all my / our
claims present or future arising directly/ indirectly in respect of the said loss/accident. I /we hereby also subrogate all my/our rights and
remedies to the company in respect of the loss/damage.
Policy No: 3105644000
*Date________________________ *Signature / Thumb Impression of Insured
(#)Claim Discharge Voucher is applicable only if required
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai 400097. India.
Toll Free: 1800 266 4545 Email:
[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
