LN
Please keep the information handy before ringing up the 24X7 call center at AIG
1800-11996 or SMS CLAIMS to 58888 pers
‘THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY. yuyu aways
PLEASE SIGN ON BOTH SIDES OF CLAIM FORM. DO NOT LEAVE ANY COLUMN UNANSWERED.
Claim No. Policy no.
Vehicle No. Eng No. Chassis No.
INSURED/CLAIMANT NAME:
Address:
City Pin,
Mob Tel Res Tel off
Time & Date of Accident / Occurrence Hrs Place of Accident
Type of Loss (details overleaf) [OWN DAMAGE CI) THIRD PARTY C1 Bodily Injury 1 Property
Damage Short Description of Accident/Incidence (Sketch overleaf)
Tobe filled only in commercial vehi
Permit valid upto Fitness valid upto
Load carried at the time of accident No. of passengers carried at the time of accident
Police FIR no, (lodged if anv). Police Station.
Details of the driver at the subject time of accident
+ Name ‘Age __ Occupation,
+ Driveris[] Owner [Paid Driver] Relative/ Friend
+ Driving License No. Badge no
+ _Effective for (type of vehicles) Effective upto:
Please enciose seif~ certified copies of Registration Certificate, Driving License, Fitness & Permit Certificate (bythe insured as applicable). Also please
{enclose copies of Police Report and Fire Brigade Report, if odgec.
DECLARATION
Mle agree to provide additional information to the Company, if required. I/We the above named, do hereby, to the best of my/our knowledge and
belief, warrant the tuth of the foregoing statement in every respec, and if I/We have made, or in any further decaration the Company may require in
respect of the sald accident, shall make any false or fraudulent statement, or any suppression or concealment, the policy shall be void anc all ights to
recover thereunder in respect of pastor future accidents shall be forfeited
{understand thatthe Company reserves the right of vericaton (*) of facts and documents relating tothe policy and cai,
Place
Date: Signature of the Insured
CLAIMS DEPARTMENT
Tata AIG General Insurance Company Ltd.
'A.801, Sth Floor, Building No.4, Infinity Park, Gen. A. K. Vaidya Marg, Dindoshi, Malad (East), Mumbai - 400 097. PT.DETAILS OF DEATH/INJURY/PROPERTY DAMAGE TO THIRD PARTIES/OCCUPANTS/DRIVER
= Name of ‘adaress | Contact Wo.) Type of inary? ] _ Name of the Dodor | Any Legal/Gour
no | The Party/Occupant/Oriver | (VilageyTown) Damage Hospital where | Attending |” Notice Rec
‘emitted
NA. Please attach deitonal sheet with full particulars, if needed,
‘Show how the accident occurred by using this diagram
=
Give street names, direction and location of objects concerned
DECLARATION
1IMle agree to provide additional information to the Company, If required. I/We the above named, do hereby, to the best of my/our knowledge and
belie, warrant the buth ofthe foregoing statement in every respect, and i /We have made, oF in any further declaration the Company may requie in
respect ofthe said acciéent, shall make any false or fraudulent statement, or any suppression or concealment, the policy small be void ane all nights to
recover thereunder in respect of pas or future accidents shal be forteted,
understand thatthe Compary reserves the right of vericaton (*) of facts and documents relating tothe policy and claim,
Place
Date: Signature of the Insured
CLAIMS DEPARTMENT
‘Tata AIG General Insurance Company Ltd.
A501, Sth Floor, Building No.4, Infinity Park, Gen. A, K. Vaidya Marg, Dindoshi, Malad (East), Mumbai - 400 097.
(Regd. Office : Peninsula Corporate Park, Nicholas Piramal Towers," Floor,G K Marg, Lower Parel Mumbai - 400013)