Livery Genera Insurance Limited {ce Fac Tower A Pennsca Besos Pak, Canoats Kaar arg Lawes Parl Mamba 400013, one 2 70a ata Faw 0912267001608 General Tnsurance. Ena caretiberinsraosin IRA egsason umber "30» CN U6sOCaMHZoI0PLCZOESSS MOTOR INSURANCE CLAIM FORM PRIVATE CAR/TWO WHEELER OF THIS CLAIM FORM IS NOTTO BE TAKEN AS AN ADMISSION OF LIAB 8a. Claim Form ob filed in canta trs and signod by tho Insured Tne samaged vile musi be parked a a safe pace fo volt any subsoquont os ho. © Pe sum! the documents as menboned an he rvecee os fom 4. Plans donot nave any cour unanswered; Manson ‘NI not appcabl, Ir any infomation is nol esi svalabe plese dono ey the dapach of Bs orm and ole prteuars may be sen tr Ply Number - - - | am Numb Petiod of insurance 77 el eaI7 am of he nau iy ‘Contat Nornbors Prone STO Code E-mail DS Pin ode ate Time AM IPM Location [ ty TTTTTTTT ttt sate [ Pin Code I ood ype: Ewes way THIROod Rana! Ste gay 1GHy/Town Rand C1 Dael Read Obes Speed atthe sna of accsent [| _] kmh “ype floes: Own Damage — Tw Pani Tat (pay Ted Paty Dent Tas Pany cy CT Party Property Damage Persona Accent pose for wich te vehi was bing used a eine of ert hat unser fprsonsroating [[[_] Any oher vie nod tn ate of et tesa the possesion 0? neve [TI ml ‘contac. “Hobie andre Cora Deals of person a 8 Lenton Nara Relauonaipw ae Cone Nba: Prone STO Gale Emad Deserbe Cause of Los / Damage / Accent Pate craw 2 skoch of spot of accident & doscre postion of vai athe tins of accant, including nearby landmarks FIR/DOR/GOR Mary: C1Yes Ne nat (easons) Police FIR GOR/ DDR Det No ET TT | owe fof To fof fe TT] Police Staton name ow CTTT StateLivery Genera Insurance Limited Phone: #9122 6700 1313 Fax +91 226700 1608 General Insurance. Ena caretiberinsraosin IRA regaatan ruber "90> CIN UssooaMH2010PLC206556 Fs, No Mako Chassis No, Enaine No Engl Cobur Data oF Reaiaon TO radebon Vohice Gass FE Two Wheslar 1PM Car Obes (saat Name ofcvtrer [_T VEE Rostostie win nse LLL comer om oF Quattcaton: S Betw 10h Se, T1OH Pass Cah Pass 0 Grdiabon TPG ‘contac Number: Prone. STO Cade No E-al0 Driving License Ne Date osu Date of Expy Issuing R70 Type of License: Permanent Temporary Class: Mylo WIG OMCyele ols TLMY CI Teanspert )Non-Transpet CHGY — Passenger Special Endorsements any ES (tach sesonal shoot, reared) si] Nameofperson | Whether TP | Address | Contact No, | DesthType [Name of iospital| | Name of | Deals of Any Legal No! Peston ‘oTinjury”_| where admited | Aitending Doctor | Court Notice received ‘ny over infomation ie, the above named, do hereby, othe best of myour nowedge and bela, watrant the tuth ofthe foegoing statements i ever respect and we agree that ‘Ws have made, orn any turer decarton, te Company may fete respect a he sald acidar, shal make any false o faudulent talemert & siy Suppression ar eoncealmant he Company may fre te aire cla, an the Poleyshallbe hu ahd vo nd al hghs to recover there unde espec of past ‘or fiture lsslacdants sal be orf, Le have tached the at of documents wih tis cam Form and have understood the ene equrement tobe fled for admintraton of is sim and ne (Company sna nt beheld response fr any dey ettament of clam duo non ‘uflment of requrementsincuaing the document a menoned inthe ca form We agre o provide adetona iformaton and adetonal documertaton tothe Company, aquired. We futher authorse the Company to access mylour Information relevant othe Gam unger rocees Place LILI] ‘Signature ae ane ot rst aman ForAcldnt Cine For The Caine 1 Pt franca Pay Cov No oy 1 Ogle dune i 2 Gop Regataton ctor 2 OidralRogonton Book Carta ard Tx Payment Resp i (Pesto nga otto 3 Rita tye Sarce Bt Waray CaCl Pachaseoke | 8 3. Sepyottier Onin cers oft pon ng the voile at | & Polos Panchina an il Ropar hence Repo } enous oye aeead RTO hat ef nt nomng ‘ Nowuse! i 5: Exot ftps tome ephe whee the vel 6. Pom 8 and 30 signed heared and Form 5 led by he andr roped 7 Sieeion um spd Portnoy 3 6, Rept Berle an payment cp are bacon | & ana cms mater youre and France i 1 DchgeVouner 2 Notun te Pranctfcariatoe seed youre i fo. Indeoiy sora bday ue’ } ar caer rae yan be te You nd won aie