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)