Form No.

UNITED INDIA INSURANCE COMPANY LIMITED

Registered & Head Office, 24 - Whites Road, Chennai - 600 014.

MOTOR CLAIM FORM - TWO WHEELER / PRIVATE CAR

Page 1 of 1

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

Instructions for filling the form:
(a) Complete all relevant details fully. (b) Where boxes are provided enter one letter per box.(c) Where check boxes are provided indicate selection using a tick mark.

CLAIM NUMBER
(For official use only)
POLICY NUMBER
INSURED NAME

INSURED ADDRESS

Pincode

Mobile

STD Code

Landline

E-Mail

@
-

Registration Number

Chassis Number

VEHICLE DETAILS

Engine Number
Make

Model

Hypothecation
Details
Date of loss

DATE & PLACE OF LOSS

Time

a.m. / p.m.

Place of Accident /
Theft
Driver Name
Driver Address

DRIVER DETAILS
Driving Licence Number
Licence Expiry Date

Was driver under influnence of drugs / intoxicants

Yes

Issuing RTA
Was driverinjured

No

Yes

No

Provide brief description of accident / theft / occurrence. (Attach separate sheet if required) (Provide a rough sketch of accident location):

ACCIDENT
DETAILS
Two Wheeler (Additional Info)

Pillion rider carried

Private Car / Two Wheeler

No. of Occupants carried

Yes

No

Address of Workshop

WORKSHOP DETAILS

Workshop Contact

Estimated Loss

Workshop Mobile

Workshop Phone

Workshop Fax

Workshop E-mail

Theft of vehicle

THEFT DETAILS

Accessory Name

(If accessories stolen provide detail as below in a separate sheet)

Theft of accessories
Make & Brand

Serial Number

Accessory Insured
Yes / No

Accident / Theft reported to police

FIR DETAILS
(Applicable for theft, fire, loss of
personal efects& third party lossonly)

Yes

Date of reporting to police

If No provide reasons

No
/

Accessory IDV
Rs.

Name of police station

FIR / Crime diary number
Third party involved

Yes

No

Third party loss type

Death

Injury

Driver Injured

THIRD PARTY LOSS

DETAILS

Details of Third party loss

(Attach separate sheet)

Yes

Witness Details

ADD ON COVERS
(If applicable)

INSURED BANK DETAILS

No

Name

Age

Loss
type

(If "Yes", provide additional information)

Property Damage

Treatment
Undergone

Name

Hospital
Details

Phone

No
Third Party Vehicle
Number (If applicable)

Address

Courtesy car facility availed (Private Car Only)

Yes

No

Medical expenses required (Private Car Only)

Loss of personal effects (Private Car Only)
Account number
Account number

Yes

No

Rs.

Yes

Occupants Injured
Address

Remarks

Phone

If Yes, Expected repair completion date

Likely expenses
(List items lost with value as a separate sheet. FIR MANDATORY)

Branch Name

Bank Name
IFSC Code Number

DECLARATION BY 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 that I / We have made, or in any
further declaration the company may require in respect of the said accident, shall make any false or fraudulent 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.

Date:
Place:

Signature of Insured / Claimant