Name of Third Partyl Address Name of the

; Sr No.
Occupant /Driver (Village/Town) Contact No.
Type of lnjury/
Hospital where Doctor
Damage Attending
admitted

."i

N.B. Ptease attach

----"*---*J

Show how the: accideni oCr'urred,by ilsing this diagrarn

to
6\tr

-
aqtr Give street and location of n

the policies, directlyto myy'our:

2 Permanent Account Number (pAN)

3 Particulars of Bank Account
Name of Bank
Name of Branch

City Name
PIN No.
'IFSC Code
of Account
TrTpe
Savings Curaent
Account Number
4 Payee's email lD

Piease attach a cancelled cheque

to the above.
Declaration: We hereby declare that lhe particulars given
above are correct and complete.

lArVe agree to provide additional in{ormarion to the

myior-ir knowleclge and berie{, warrant the truth
further declaration the Company may require in respect
or any suppression or concealment, the policy
accidents shall be forfeited.
the Company
Company, if required. IAly'e the above named, do he,eby, to the besl 01
of the foregoing statement in every respect,
and i{ lA/i/e have made, or in anY
of the said accident, shall make any false or
fraudulent statement,
shall be void and all rights to recover thereunder
ir respect of past or Iuture
the right oIver;ficaLion (*)of facts and documenls
relating lo the policy and claim.

Date:
i+r$lfrr
Tata AIG General lnsurance Company Limited.
Signature of the Insured :

A 501,Sth Froo4 Building No, 4, rnfinrty park, Dindoshi,

Marad (Easti, Mumbai 400:097.

TataAlGGenerallnsurancecompany.Ltd.Regdoffice:.15thflqor,TowerA,PeninSulaBusinessPark,
GanpatfaoKadamMarg,offSenapati]BapatMarg,LowerParel,Mumbai.400013

vER.2/i\rAR/2013