CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Registered and Head-office:Dare House, 2nd Floor,No.2,NSC Bose

Road,
Chennai,600 001.
MOTOR INSURANCE CLAIM FORM
(The issuance of this form doesnt imply admission of liability)

Policy/CoverNote Number: 3397/60489171/000/00 Claim NO: 3397234708

Policy Period From: 11-11-2023 Policy Period To: 10-11-2028

Region : MADHYA PRADESH STATE
OFFICE

Personal Details

First Name: SHYAM SINGH Middle Name: Last Name

VISHWAKARAMA
Gender: Male Date of Birth : Marital status Married
Occupation: Salaried Aadhar No: 951765632421 Mobile No: 9039670983
Pan/Passport/Dl NO: BTTPV8499P Tel(O) No: Tel(R) No:
Email ID:

Correspondence Address

Door/Flat HARRAKHEDA GRAM Building No/ Name: Street Name:

No: HARRAKHEDA||
BHOPAL
LandMark: Sub Area/Village: Area/Tahsil:
City: TARAWALI KALAN District: BHOPAL PinCode: 462101
B.O
State: MADHYA PRADESH

Permanant Address

Door/Flat Building No/ Name: Street Name:

No:
LandMark: Sub Area/Village: Area/Tahsil:
City: District: PinCode:
State:

Vehicle Details:
 Registration NO: MP04ZR1492 Date of Registration: Engine NO:
Make TVS Chasis NO: Model: RAIDER 125 - DISC
BSVI
FC NO: FC Validity: Permit NO:
Permit Validity: LR NO: LR Date
Mileage: Financial Interest If Any..

Loss Details:

Date of Loss : 16-12-2023 Time of Loss : 20:00:00 AM/PM

Place of Loss: BERASIA BHOPAL S.O,BHOPAL State : MADHYA PRADESH

No of Persons Travelling in the vehicle : Occupants: Fare Paying Passengers:

For What Purpose was the vehicle being used at the time of accident : Private

Nature and weight of the Goods Carried (for Goods carrying Vehicle) :
Travelling From : TRAWALI Travelling To: BERASIA

Any third party was involved in the accident :

Was the Accident/Theft reported to police :

Name of police station : CR Dairy No :

Description of the Accident/Theft :

Claim on Add on Covers under Chola Protect

SlNo Name of the Item Model/Serial No/DL number (issuing Authority) Values In Rs

Garage Name: DANGI MOTORS Phone: Estimated Loss:

Date of Vehicle TIme of Vehicle left
Left to garrage: to garrage:

Driver Details:

Name of the RAMBABU Date of 01/05/1998 Age: 25

Driver: VISHWAKARMA Birth:
Driving License MP0420221002185 Date of 14/03/2022 Name of MADHAYA
No: Issue: Issuing PRADESH
Authority:
Location of BHOPAL Date of 2038-04- Type of Vehicle LMV(NT)
Issuing Expiry: 13T00:00:00.0 Authorized to
Authority: Drive:
Driver Relation: Relative

Injury to third party/Occupants/Driver

 Name Address Nature of Injury(RH No) Whether Third
Party/Occupants/Driver

Details of Third Party Damage:

Other Insurance Details:

Is there any other Insurance Policy Ideminifying you in respect of this Accident/Theft
:

If Yes Policy No: Name of the Company/Office:

I/we hereby declare that the aboue particulars are trueand correct in each and every aspect.I agree to provide any
further information/documents/Assistance that may be required for processing my/our claims.In case of any
information furnished by me/representative is found incorrect,we agree to accept the decission of the company on
admissibility of claim.
Date:

Place: Signature of the Applicant:

I/we hereby authorize Cholamandalam MS General Insurance company Ltd to transfer the Claim Amount Payable under Claim
No: 3397234708 to my bank Account No: with

bank in branch,located city. The MICR code is

at

and the IFSC code is .Account Type:

Date: Signature of the Applicant:

Place:

Documents Enclosed (For Office use only)

Claim Form Submitted Verified Permit Submitted Verified

RC Copy Submitted Verified TripSheet/LoadChalla Submitted Verified

n

DL Copy Submitted Verified Policy Copy Submitted Verified

FIR Submitted Verified FC Submitted Verified

Repair Estimate Submitted Verified Invoice Submitted Verified

Discharge Please return this Receipt duly stamped and signed to enable the company to make the
Voucher payment
Recieved a sum of rupees towards the full and the final settlement of Claim No: 3397234708

The Liability has been Explined to me

rs Affix Re 1/-
Revenue Stamp
Witness

Signature of the Repairer with Seal

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Registered and Head-office:Dare House, 2nd Floor,No.2,NSC Bose Road,
Chennai,600 001.

MOTOR INSURANCE CLAIM FORM

(The issuance of this form doesnt imply admission of liability)

List of Documents Required for Claim Settelment

(To be submitted to near by Cholamandalam MS Office/Surveyor/Repairer)

Claims for Accidental Damages:

1)Proof of insurance-Policy/Covernote Copy

2)Copy of Registration Book,Tax receipt(please furnish original for verification)
3)Copy of Motor Driving License(with original)of the person driving the vehicle at the material time.
4)Police Panchanama/FIR(in case of third party property damage/Death/Body Injury/major loss claims)
5)Estimate for Repairs from garragewhere vehicle is to be repaired.
6)Repair Bills and Payment Reciepts after the job is completed.
7)Cancelled Chq Leaf for NEFT transfer.
8)Please signed the attached discharge Voucher after confirmation of the Claim Amount.

For Assistance please call us at our Toll free No: 1 800 200 55 44

Satisfaction Please return this Receipt duly stamped and signed to enable the company to make the payment
Voucher
 "We hereby Confirm that vehicle NO has been fully repaired to my satisfaction and hereby fully
discarge Cholamandalam General nsurance Company Ltd.,from all liabilities under this Claim.I/We also agree to pay my

share of loss,if any,directly to the repairer where cashless has been availed.

rs Affix Re 1/-
Revenue Stamp
Witness

Signature of the Repairer with Seal

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Registered and Head-office:Dare House, 2nd Floor,No.2,NSC Bose Road,
Chennai,600 001.

List of Documents Required for Claim Settelment

(To be submitted to near by Cholamandalam MS Office/Surveyor/Repairer)

Claims For Accidental Damages :

1. Original Policy Document

2. Original Registration Book/Certificate and Tax Payment Receipt.
3. Previous Insurance Details - Policy No,Insuring Office/Company,Period of Insurance
4. All the sets of Keys/Service booklet/warranty cards
5. Police Panachanama / FIR and Final Investigation Report
6. Acknowledged copy of Letter addressed to RTO intimating theft and making vehicle "NON-USE"
7. Form 28, 29 and 30 signed by the insured and Form 35 signed by the Financer,as the case may be,Undated and Blank
8. Letter of Subrogation
9. Consent towards agreed Claim Settlement value from you and Financer
10. NOC of the Financer if Claim is to be Settled in your Favour
11. Blank and Undated "Vakalatnama"
12. Cnacelled Chq Leaf of NEFT
13. Please Sign the attached Discharge Voucher after Compensation of the final Claim Amount
Additional documents in specific Claims shall be intimated seperately.

For Assistance please call us at our Toll free No: 1 800 200 55 44