yy. creat Insurance Company Limited (ncorporated in India, subsidiary of General Insurance Corporation of India) Regd. Office: Oriental House, P.B. No.7037, A-25/25, Asaf Ali Road, New Delhi 110 002 MOTOR CLAIM FORM Div. Br. Office Address, Cortificate/Policy No. Tel. No. Period of Insurance. Claim No, THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY Please answer All relevant questions fully 1. INSURED @ Name (b) _Adgress for comespondence (©)__Telephone 2TH INSURED VEHICLE Wake & Year Engine No. Registation No, Chassis No, (a) Was the vehicle in proper working condition? (b) For what purpose was the vehicle being used at the time of accident? (©) Wastrailer atiached? (A) If aMotor Cycle/scooter 1. Was aside-car attached 2._Wasapillion rider carried I ADDITIONAL INFORMATION(COMMERCIAL VEHICLE) ‘The following questions need be answered in commerci (@) Registered laden weight : (bo) Unladen Weight (©) Weight of goods cavried/Load Challan No. (@)— Nature of permit (e) Nature of goods carried (®)—— Wasthe vehicle plying for hire : (g) If Lorry/leep/Tractor, was trailor tached? (h) Number of passengers carried : (@) Number of Passenger permitted vehicles only: