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THB ORIENTAL INSURANCE COMPANY LIMITED
SBRVICE CENTRBO HYDERABAD

MOTOR (Op) CTAIM TNTTMATTON

1. NAME OF TITE INFORMANT PH.NO.
2. POLICY/C.NOTf, NO. & POI
3. INST]RED'S NAME
PH.NO.
4, VEHICLE NO.
5. TYPE/CLASS OF VEIIICLE
6. DATE & PLACE OFACCIDENT
7. DESCRIPTION OF ACCIDENT

8. DRIVER'S NAME
9. NAME OF PS IF REPORTED
10. SPOT SURVEY DETAILS
11. PLACE WHERE VEHICLE IS KEPT
12. woRK sHoP NAME, ADDRESS & PH.NO.

13. ESTIMATION
14. CONTACT PERSON & PH.NO.

INTIMATION RECEIVED BY:

DATE:
SIGNATURE

SURVf, YOR/IIIVE STIGATOR :

ACKNOWLEDGEMENT OFFICE NO. 23314646

23312331
2330 2178

cLArM REF.NO. (PL QUOTE IN ALL FUTURE CORRESPONDAI\CE)

SURYEYOR NAME & TELEPHONE NO.

 THE ORIENTAL INSURANCE CO. LTD.
Regd. & Head 0flice : "Oriental House", A-25l2l,Asaf Ali Road, New Dethi - il0 002.
TIIEGRI
l!ll';Aucf-c0. LTD,

Policy / Covernote No.

Policy lssuing
Office Address :
Period of lnsurance

TO BETAKEN AS AN ADMISSION OF LIABILITY

Tel. No. PLEASE AI.ISWER ALL RELEVANT QUESTIONS FULLY.

1. INSURED

(c) Telephone

2. THE INSURED Make Year:

Chassis No.
VEHICLE
Engine No.

Registration No.:
a) Was the Vehicle in proper working condition (Prior to accident)?: Yes / No
b) For what purpose was the vehicle being used at the time of accident ?:
Social Purpose / Domestic Purpose / Pleasure Purpose i Own Business / Hire &
Reward / Racing / Others (Pl. specify) ............:..!... ...................

Documents required c) Was trailer attached (in case of Tractor / Jeep I Lorry) ? : Yes / No / NA
1. Estimate d) Number of Passengers Carried .................:........ j............ .. (lnclusive of Driver)

2. Policy Copy e) lf a motor cycle i scooter

3. Registration Certificate
4. Driving Licence
Addl. Documents (ln case of
CommercialVehicles)
5. Fitness Certificate
6. Route Permit
7. Consignment Note / Load
Challan /Trip-Sheet
8. Police Report
1. Was a side car attached ? Yes/No/NA
2. Was a Pillion Rider carried ? Yes/No/NA
ADDTTTONAL INFORMATTON (COMMERCTAL VEHTCLES)
The following questions need be answered in case of commercial vehicle only
a) Registered laden weight / Gross Vehicle Weight : ................
b)
c) Weight of goods carried
d) Tripsheet / Load Challan No.: ...................... Date
e) Name of the Consignor'
0 Route

Other Documents s) Permit Number

h) Nature of permit : National Permit / State Permit / Contract Carriage / Stage Carriage
9. Fire Brigade Report
(in case of Fire) i) Nature of goods carried

10.Other Documents i) Was the vehicle plying for hire ? Yes / No

(as specified by us)
k) Fitness certificate No.
 a) Name of the Driver

b) Age

c) Address

d) ls the driver 1. Owner - Yes / No

2. Paid driver Yes / No

3. Owner's relative or lriend Yes / No

e) lf paid driver how long has he been in your

employment?

0 Was he under the lnfluence of intoxicating

liquor or drugs ? Yes / No

3. DRIVER ATTHE g) Driving Licence Number

TIME OF h) lssuing AuthoritY
ACCIDENT
i) Date of Expiry
j) Was the licence temporary / permanent? ...........Temporary I Permanenl

k) Type of Vehicle authorised to drive

l) Details of endorsement / suspension, if any

m) Badge No. (lf anY)

n) Has he been involved in any accident before?:

o) Has he been charged bY the Police? Yes I No

lf so, why

Any other insurance PolicY / ies Yes I No

4. OTHER
indemnifying you in respect of this
INSURANCE accident? (lf Yes, Please give details)

a) Date & Time of Accident

b) Place: . on Route From............................-To

c) Speed of your vehicle at the time ol accident kmph

d) Give a short destruction of the accident

5. DETAILS OF
ACCIDENT

Was any third PartY resPonsible Yes I No

for the accident ?

lf yes, their Vehicle No.
 a) Fulldetails of damage

6. DAMAGE TO
b) Estimated cost of repairs
INSURED
VEHICLE c) Where and when can the
damaged vehicle be inspected?

Give Name and addresses of passengers /

other Witnesses, if any

b) Was accident reported to police? Yes / No

c) lf not why?
7. ACTION TAKEN
d) lf yes, lo which police station? P.S.

e) CR Diary Number

0 Was Spot Survey done? Yes / No

ll not, why?

a) Date &Time

b) Place

c) What was Stolen?

8. THEFT
d) Estimated cost of replacement

e) By whom discovered and reported?

0 Has theft been reported to police? Yes / No

g) When?

h) Which police station?

i) CR Diary Number
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rH E oRr ENrAL INSU RANcE .o tt" co ra
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DISHARGE VOUCHER ( To be taken in duplicate fm,l

Deptt: Claim No.

Ref no : Policy No.
Date:
ln consideration of approval of my / our claim I / we hereby accept frsm the
Oriental lnsurance Company Limited the sum of
Rs. 'Rupee s Only
(approved'net claim amount) in

full and final settlement of my / our claim for the loss of

{Property) which occured on (date of loss) covered under the
policy no. for the period from to

Motor Deptt: vehcile No. Make

Fire lMisc deptt : Details of property :
Marine : A WB I RR IBL / No & Date ___ Vesel

ll we hereby voluntarily give discharge receipt to the company in full & finalsellle:
ment of all my / our claims present or future arising directly / indirectly in respect
ol said loss / accident. | / We hereby also subrogate all my I our rights and rem-
edies to the Company in respect pf the above loss / damages.

Rs.

One Rupee Revenue Stamp

when clainr Amount Exeeds
Rs. 5000/-

Counter signature of the Financor ( in case of signature of claimaint / '

Total loss ) with Rubber Stamp. lnsured :

Full Nam.r :

Address
Accounl No

Witness (in case of illiterate, Branch lVr.'nnger to

Signature Ver ify thurnb impreessicri;
Full Name
Addres
Tel No

samatha/06-07/