ena Ale const cone eC US Call our 24x7 Helpline 1800 266 7780 or SMS ‘CLAIMS' to 5616181. Nore 1) Please koop the information handy before calling up the helpline number. 2) Tha issue of this form ie not tobe taken as an admission of liabilty by Tata AIG, {3 Pease sign on both sides of claim form. De nat lave any column unanswered. 4) Please enclose set certified copies of Regsration Cerificate and Driving License, Fitness & Permit Cercate fy the ineured se applicable), 5 Also please enclose copies of police report and fre brigade report iflodged, Chaim No: Policy No: Vehicle Ne: Insured/Ciaimant Name: Email ld Address: City: Pin Mobile Tel Res Tel oft Time & Dato of Accident / Occurrence Hes [Jam [7] pm Place of Accident: Typo of Loss details overeat): [_] Own Damage [_] hid Paty []Boaiyriury [_] Property Short description of accident/incident (sketch avereaf} Driver's Name: etectvefortypeotveies: (TET TI ITI EI LL) — eiveae: CO) C1) Load carried at the time of accident No. of passengers carrod at tho ime of accidant: LILI FIR Date: Police FIR no. ff any lodges Police Station:Insurance ith Name of he Name of Tid Pay’ | Adress Te ota | ,Namectte | oct | any Lagavcour Seno. | “Steupantdver” | witgeonn) | ComeetNo. | ™iSsmage™ | Hoxntalwhore | acencing | Note Rect NB Please sttach additonal shoot wih fll paris, Freese, ‘Show how the accident occurred by using this diagram Give street names, direction and location of abjects concerned EFT Mandate for Claim Payment 11 We hereby authorize Tata AIG General Insurance Co Ltd to pay the tenable claims under our insurance policies issued by Tata AIG General Insurance Co Ltd as per terms and conditions of the policies, directly to my /our below mentioned Bank Account in India 1 Payae Name Insured Name 2 Permanent Account Number (PAN) 3 Particulars of Bank Account Name of Bank Name of Branch dares GiyName NN Fc Code CCPC errr Tipe of Account Sevnos_[ | cone ‘Account Number 4 Payoo's email ID Please attach a cancelled cheque pertaining tothe Account furnished above Declaration: We hereby declare that the particulars given above are correc: and complete [Mie agree to provide additional information to the Company, if required. (We the above named, do hereby, to the best of ‘mylour knowledge and belie, warrant he truth ofthe foregoing statement in every respect, and if Wee have made, orin any further declaration the Company may require in respect of the said accident, shall make any false or fraudulent statement, fr any suppression or concealment, the policy shall be void and all Fights to recover thereunder in respect of past or future accidents shal be forfeited lunderstand that the Company reserves the right of verification(*) of facts and documents relating to the policy and claim. pate: [7] FI] CCIE] Sianature of the insured! ‘Tata AIG General Insurance Company Limited. ‘4.601, 5th Floor, Building No. 4, Infinity Park, Dindoshi, Malad (East), Mumbai 400 097. subject mater ofthe salctation. For more details on isk factors, arms and cantons, paso read soles brochure cartuly before concluding a sae. Tata AIG General insurance Company Ltd. Regd Ofee- 15th oor, Tower, Peninsula dusiness Pak, ‘Ganpatran Kadam Marg, Of Senapat Bapat Marg, Lower Pare, Mura 400 013.