GENERAL teliancegeneral.co.in ASS INSURANCE 1800 3009 ‘A RELIANCE CAPITAL COMPANY Motor Claim Form (issuance of this form dows not imply acceptance ofthe lability) Al elds in the form are mandatory Enon jant (Owner) Tobe filed in BLOCK LETTERS Policy No. Cover Note No, Policy Period From e Full Name Meshes. ‘Acéress for Communication Flat Building l RoadiSteetiSector L Nearest Landmars Loe ee Le Ll Ll TalukaVilageMDisticuCity pep | pincode Ly State ‘Change ofthe contact Details] Yes, wish to change my contact details] There is no change in my contact details, Please update mentioned mobile number as prmary contact details against my poli. | also hereby confm to be contacted on the number provided above for Claim Status (Policy Renowal Phone No, Lever iiiiit MobileNo. L111 1 4 1 1 1 1 1 J Alternate Phone No. Leer iii | Atemate mobileNo Lair 1 rr a i | Email ID DOB [aya |my ml i ‘Aadhnaar(UIDAI) No. PANO: Loto td Insured Profession 1 Private Service C Set Employed LI Poltician C1 Retired L] Student C] Government Service] House Wife Monthly Income upto £20,000 C1 # 20,001 to 250,000 LI 50,001 to 1,00,000 C1 £ 1,00,001 ane above ‘Any claims made in last wo insurance poles [] Yes [] No Ifyes, please spectty Toren Lever iiiiiid Leeder yy Dato of Registration Registration No, Date of Purchase of Vehicle = Lut Ly wl vy viva J Ey of Trp. Rog tna Letool yy vivid Chassis No. L Engine No. J Make L J oder L | Class of Vehicle Oe Otwowneeler Ccommercial Financiers OYes [1 No ifyes, Name of Financier Date. L 1 1 J Time L 1 | amipm_ Vehicle Speed: Police FIR No. GD Eniery avinaiom) L111 1 4 1 1 1 1 Name of Police Station Name of Garage l J Estimate of Loss Lae Garage La No. of persons traveling atthe time of accident excluding criver Description ofthe accent (Please attach a separate shest if needed) For what purpose was the vehicle being used atthe ime of accident? [] Personal []ForHire of Passenger [Carriage of Goods Vehicle was plying trom to Was any third party involve in the accident [] Yes [] No ifs, Vehicle No. and details Diagram of location of accident, positin of your vehicle, cecton in which you vehicle was moving. Stret name, nearest landmark’shopibuilding ‘in shase he damaged poron Senta Layout SW I ‘An 180 9001:2008 Cortied Comany IRDAI Registration No. 103. Reliance General Insurance Company Limited. Registered Offic: H Block. 1" Floor, Dhrub Ambani Knowledge City, Navi ‘Mumbal-400710. Corporate Office: Relance Cente, South Wing &”Foor, Of. Westem Express Highway, Santacruz (East), Mumba -400 055. Corporateldenty "amber Usss031#H2000PLC128300. Trade Logo dsplayed above belongs to Ani Ohubhal Aman Ventures Private Limited and used by Reliance General Insurance Company Limited under License, RGIMCOMICOMOT-2ICLNEFMIVer? 2060617Name L jl ComespondenceAdcress Ly yb Telephone Number | rr Gender: Male / Female Date of Birth Lora} ol yy Licence No, La a a Licensing Authority Lrritiririiis ‘Valid upto Set “ype of Vehicle authorised to Drive: CHV — Transport «= CMV 1. Motorcycle] Scooter Without Gear Isthe Driver’) Owner] Paid Driver] Any Other Person, please specity ‘Was the drvor under the influence of aleohot Ll Yes LINo ——TypectLicence: Permanent. Learner Driver involve in any other accident in last two years. Cl Yes CINo tyes, please provide details Details required only for Commercial Vehicle Nature of oad carried at time of accident 6. Date and No. No. of passengers carried at time of accident = L___ PermitNo, L111 1 1 1 1 J Permit valid upto Permit Issuance Date Fitness vali upto (iene ee ke ed | ‘Type of FP Loss [L_tniury Death Property damage _| Status of vetin [ Passenger iver Third person | ‘Additional information required for theft claim Place of theft Lepr} Time notices Lei 1 J Dateot thet Loven ol | Poivestaion = Ly apr yr rip yriiiiriS FikNo Lo 11114 J Date of FIR Lora} ol vy vy By whom it was frst noticed and whe Time amipm Wiinesses Name & Adéress witness Contact No. L Detals of person in whose possession the vehicle was a the time of theft Relationship Purpose ‘Add On's: 19 you wish to opt a claim for ad on cover if opted under the policy ves Ono Cover for ni Depreciator™”” 1] Motor Secure Pus") Motor Secure Premium 409] NCB Retention cover "Easy Monthy Insialment (EM) Protection Cover, 1] Plan!-1 EM! Plan -2eMls (Plan l-3 EM. Dota! cover Details of any other insurance covering this vehicle (Name of Insurance Company) L414 a ya ye yy a | Paotey No. L J Perod ofinsurance J Bank Details for NEFT payment (For Reimbursement Claims) Nome ofthe Bank Account Holéer——] MC) Mrs. 2] Ms BankAccountNo: Luau a ius | Account: Saving] Current Name ofthe Bank Lot Branch od MIGR Code (9 it MCR code number ofthe bank and ranch appoaring on te cheque esvesby obank) Lon tt a tt a | IFSC Code (11 character code appearing on yourcheque lea) L111 411 11114 1 tunderstana tat anyny end due onthe premium payment any payment / claims to be direct erected to my aforesaid Bank Account” “As por IROAI, is mandatory that al payments made ta the insured are only tough electronic mode porta Note: Please attach rgnlcancaled cheque anda copy of PAN car for vertication a I ene) ‘Aadhaar CardNo. (Note: Self attested Aadhaar card copy tobe submited) D1 iwishtocotect claim reimbursement rect in my Bank accountlinked wth my aforementioned Aadhaar Card. understand thatthe claim amount shall Do creited directly inmylatest Bank accountlinked wih my Aadhar Card liWe hereby declare tha the details given above are true and correc othe best of my belief and knowledge, Inthe event above information or any part ‘hereotis found incorrect, Lagree that alright unde the policy willbe foretelted. Ihave received and read the Claim Procedure ofthe insurer attached otis, Clam ormandretained itwith melus.| agreeto provide altonal information tthe Company required. wilindemn‘y and hold harmless the Company duet anyloss arising out of msstatementin this form, Place: Date Signature ofthe insured (U1) : RGEMO-A00-00-19-V02-12-13 (U2) : RGI-MO-A00-00-03-V01-13-14 (U3) : RGL-MO-A00-00-04-VO01-13-14 (U4) : RGEMO-A00-00-05-V01-13-14 (U5) : RGEMO-A00-00-06-VO1-13-14 (U8) : RG-MO-A00-00-17-V01-14-15GENERAL teliancegeneral.co.in ASS INSURANCE 1800 3009 ‘A RELIANCE CAPITAL COMPANY Claim Procedure: Step-by-Step Guide for Claims rons (Claim has to be intimated wit our Call Centre at 1800 30089 (tl free) Intimate the claim to the insurance company immediately. Delay in intimation would tantamount to a violation of policy condition. aa > Please provide your motile no. for sending SMS about your claim status from time to time. Ifthore has bean any injury to any passengers ora head on collsion rasuling in major damages or vehicle notin @ motorable condition due to accident please report the matter to Polce and seek a spot survey immediately before shifting the vehicle ftom the accident spot Please rush the injured tothe hospital. ‘You can seok the help of our Call Contre Executives in identiying a cashless network garago* close tothe locaton of ass. Decide onthe repairer and inform us immediately once the vehicle is left at the garage. Please try to produce the vehicle for inspection as early as possible asthe policy does not pay for consequentiallaggravated damages on account of delay, ‘Submit al documents ised on time fora speedier claim setlement* Keep original documents ready for verification by our loss assessor > Produce the vehicle for re-inspection after repairs if he Iss is above Rs.20,000. Submit bills and cash receipt wihin 10 days from the date of repair. > To pay the diference bill amount over and above the labily ofthe insurance campary before taking dalvery of the vehicle from our cashless network garage, which can be an account of depreciation, salvage, excess, Consumables oc > We suggest you to opt fr a NEFT (electronic fund transfer o your bank account direc) or Aadhaar based payment for @ hassle free claim setlement, you have not chosen to repair at our cashless network garage. Incase of a loss due to rots inform police immediatly > loss is on account of fre, inmate fre brigade immed ately and try to minimise loss. > Incase of thet claim, report the loss immesiately to the insurance company and also the police. Informing insurers immediately helps us co-ordinate withthe police for acing ofthe varicle through th investigator. > To co-operate withthe investgator ina thet claim and provide necessary information sought by him > Ifyou would lke to lodge @ claim under the personal accident cover ofthe policy for death or permanent total disablement or loss of limbs or eyes" do intimate the call contre executive of the same. “conditions ape ‘clam amount shallbe subject othe pole terms and conatons and thee snallbededucton for gepreciaton, excess eahage et. a laid dou n Plata go trough te ply documer rate Secon ilo the polcydocuman Documents to be kept ready at the time of registration of a claim » Palcy Copy > Registration Book » Driving License ‘You may nave to inform the insurer of th fllowing at the time of intimation ofa claim: > How the accident took place > “The damages suffered by the vehicle > Location ofthe accident LLacation, where the vehicle is available fr inspection Injuries to passengerserverthird partes if any [Name and partculas of driver who was driving the vehicle atthe time of accident “Trade Logo played above longs to Ani Dhirubhai Ambani Ventures Private Liited anc used by Reliance Ganeral Insurance Company Limited under cans, DE Dé Cee) Claim No. beating Ragisvaton Number Which hs been epaed to mylour stltacion and we aa that th paymeat of ‘on sceaun uch repay Ralanes General sure CorpanyLiitad tte above garages nfl achare of mle clan vpn he sl company under Place ‘Signatur ofthe Insured: Date Name of Insured ty, Naw Muro 400710. \U66603102000P.6128500. Trade Logo deplayed above belong lo An Dhubhal Ambani Varures PrvaDocuments required for processing of a claim ey eee Ce Personal Accident ey Coy 7 z z RETRO Taro ¥ 7 ~ Beng eons Oy ra * = Signal tate Ropar % = = Orgel Ropar els ard payee % = = 4, rittapy tc of prios ar et. zo 3 5 3 Garste Ghats orth toro Sa aaa Raha Can Copy Wapmay—| —7 7 7 3 [ert soanvant rg aus Car ¥ % ¥ § [Gancteal ori payne ore pa ¥ * ¥ © [Coan documents for EMI payment for EMI protector v * * ‘Auto Loan Account No. v * x Farce nabs Copy z = = Vehicle Fitness Certificate Copy v vo x Passage aa eS z = = Sr = y = Car soySa ana = y = RO font Finan’ pte : Z = rom ca ee : 4 = Past Mat es é = Tapa Cott WPT o Ton = z % Tt ono lel Sa pape” = = 7 riers oer eae spoT pata GODT = 7 ‘Sep requres incase of company “Orginal docoment to be prods for vereaton ofthe evra he tim of accident “= Agpleabe for eommercel vel oly Incase necessary nddonal docoments may be requir for processing of chim Ese You can always rack your claim status > On our website - ww.rellancegeneralco.n, in the ‘Claims’ section > Through the Automated Interactive Voice Recorder System at our Call Centre or speak to our Call Centre Exscutves at 1800 3009 (oe) > SMS claimsiatus lssvarce of hie ousher et tobe taken at omission ot ab.