Call our 24x7 Helpline 1800 266 7780 or SMS 'CLAIMS' to 5616181.

NOTE:
1) Please keep the information handy before calling up the helpline number.
2) T he issue of this form is not to be taken as an admission of liability by Tata AIG.
3) Please sign on both sides of claim form. Do not leave any column unanswered.
4) Please enclose self-certified copies of Registration Certificate and Driving License, Fitness & Permit Certificate (by the insured as applicable).
5) Also please enclose copies of police report and fire brigade report, if lodged.

Details of Insured/Claimant

Claim No.:1 I I I I I Vehicle No.:

Insured/Claimant Name: �I R_l�

A l __,_ H l __,_
G l__,_ A l�V I�I
A N�---'----'--'--'---'-�������__,___,___,_���---'----'-�
E-mail Id: IK R A G HIA IV V B i N D H U @ G M i L . C O M

Address: I 3 I / I 52I I MIO I O I N IG I i I L I K IU T T H U K K A D U P M P A L A Y A M

I R I A I S I i I P IU I R I A I MI I I I I I I

City: I NIA IM I A I K I K IA IL I I I I I I Pin: 6 3 7 4 0 7 Mobile: 8 8 8 3 7 2 9 2 4 2

Tel Res.: I I I I I I I I I I I I I Tel Off.: ��I I I I I I I

Description of the Accident: Your Account

T ime & Date of Accident / Occurrence 0 3 Hrs D

[IJ X am D pm 1 1 IM
@:IQ] 1IM1I I Y2I0YI 2YI YI
3
Place of Accident: I T Ii I R I U IP I A I T I H I i I T IE IM I P IL IE I R I OI AI D I I I I I I I I I I

Type of Loss (details overleaf): DX Own Damage D Third Party D Bodily Injury D Property
While going to temple by mistake i have hit my car to the barrigade
Short description of accident/incident (sketch overleaf): __________________ _

Driver Details (at the time of accident)

Driver's Name: �I �l
R� A l __,_ H ��
G l __,_ IA V �
A ---'----'--'--'---'-
N �������__,___,___,_���---'----'--'--'---'---'-----'
Age: [IJ
2 7 ������-��-��-��-��������-���
Occupation: I S A P C O N S U L T A N T

Driving License No.: I T NI 2 I8 ZI2 0I1 7 I0 0 I0 3I5 4I 2 Badge No.: I I I I I

Effective for (type of vehicles): I I I I I I I I I I Expiry Date: [IJ
3 0 [IJ
I 0 '-���
I2 0 3 7

To be filled only in case of Commercial Vehicle

Permit validity upto: I I I I I I I I I I I Fitness validity upto: I�__,_��---'----'--'--'-��

I
Load carried at the time of accident: I I I I I I I

No. of passengers carried at the time of accident: �

l l�l�l�I�-��-��-��-������

Police

FIR Date:@:Ig] � I YI YI YI YI Police FIR no. (if any lodged): '-I-'---'-����.,______,

Police Station: I I I I I I
AMBA T T UR
17 1 1 2 0 2 3