SBI General Insurance Company Limited
PRIVATE CAR / TWO WHEELER INSURANCE POLICY - PACKAGE Claim Form
Policy No. Period of Insurance From
D D M M Y Y Y Y
Call (Toll Free) 1800 22 1111 | 1800 102 1111 www.sbigeneral.in
Claim No. To
D D M M Y Y Y Y
A. DETAILS OF INSURED/CLAIMANT 1. Name as per Policy 2. Address
(Please note if the Claim is approved, cheque shall be despatched at the address mentioned here in) S U R N A M E M I D D L E N A M E F I R S T N A M E
Plot No/Door No. Road City State
Building Name Area Pincode
3. Contact Details
Phone No. Fax No. E-mail Id
Mobile
B. VEHICLE DETAILS 1. Registration No. 2. Engine No. 3. Model 4. Date of Registration 5. Date of Transfer (if any) 6. Financiers interest if any
D D D D M M M M Y Y Y Y Y Y Y Y
Chassis No. Make Type of Fuel RTO Vehicle Class
C. DETAILS OF ACCIDENT/THEFT 1. Date of Accident/Theft 2. Place/Location of
Accident/Theft
D D M M Y Y Y Y
Time of Accident/Theft
A.M. / P .M.
Speed
km/hr
Plot No/Door No. Road City State
Building Name Area Pincode
3. Purpose for which vehicle was
being used at the time of Accident/Theft
4. Nature & weight of goods carried at the time of accident (Commercial Vehicle) 5. No. of people travelling in the insured vehicle at the time of accident 6. Is loss reported to Police? 7. Is loss reported to Fire Brigade? Yes Yes No No Police Station Fire Station Diary / FIR No. Reference No.
Version 1.2, Dec 2011
1
Corporate & Registered Office: Natraj, 101, 201 & 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai - 400 069.
D. PLEASE DESCRIBE THE ACCIDENT / THEFT (Please attach a separate sheet if needed)
E. GARAGE / WORKSHOP DETAILS ( NOTE- PLEASE DO NOT DISMANTLE THE VEHICLE BEFORE SURVEY) 1. Name of Garage/Workshop
2. Name of Contact Person 3. Garage Address
Plot No/Door No. Road City State
Building Name Area Pincode
4. Contact No. F. DETAILS OF DRIVER AT THE TIME OF ACCIDENT 1. Name of Driver 2. Contact No. 3. Driving License No. 4. Class of Vehicle authorised to drive 5. Licence Issue Date 6. Badge No. G. OCCUPANT / PASSENGER / THIRD PARTY INJURY DETAILS Sl. No. Name Address
D D M M Y Y Y Y
Estimated Loss Amount
Relationship with Insured Issuing RTO Licence Type : Permanent Temporary
Expiry Date
(wherever applicable)
Contact No.
Age
Occupant/Passenger travelling in what capacity
Nature of injury
1. Third party property damage detail (Also including other vehicle if any involved)
In case of additional information please attach a separate sheet H. WITNESS DETAILS 1. Were there any witnesses to the loss / accident ? If Yes, please provide below details Sl. No. Name Address Yes No
Contact No.
I. PAYMENT DETAILS 1. Would you like to opt for NEFT payment? If 'Yes', please enclose a cancelled cheque leaf along with the Claim Form Bank Name City Account No. Name of Payee J. OTHER INSURANCE DETAILS 1. If there is any other insurance policy indemnifying you in respect this accident? If 'Yes', please provide details Name of Insurer Address Plot No/Door No. Road City State Policy No. Period of Insurance From
D D M M Y Y Y Y
Yes
No
Branch State IFSC Code
Yes
No
Building Name Area Pincode
To
DECLARATION I/we hereby declare that to the best of my/our knowledge and belief the information provided by me/us are full and true and agree that if I/we have made any false or fraudulent statement or there be any suppression or concealment of fact, the policy shall be cancelled and claim shall be forfeited. I/we have received a list of documents with this claim Form to be submitted by me/us and have understood the entire requirement to be fulfilled for administration of this claim and the Company shall not be held responsible for any delay in settlement of claim due to non-fulfilment of requirements including the documents as mentioned in the claim form. I/we agree to provide additional information and additional documentation to the Company, if required.
Place
Date
Signature of Insured/Claimant
If any detail or information is not readily available please do not delay the dispatch of this form and such particulars may be sent later. The issue & acceptance of this form cannot be taken as an admission of liability.
INDICATIVE LIST OF DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT*
For Accident Claims
1. Duly filled and signed claim form. 2. Proof of insurance - Policy copy 3. Copy of Registration Book (Please furnish original for verification) OR Tax Receipt & Vehicle Purchase Invoice in case of new vehicle where RC is not received. (Please furnish original for verification) 4. Copy of Motor Driving License of the person driving the vehicle at the time of accident (Please furnish original for verification) 5. Police Panchanama / FIR (In case of Third Party property damage / Death / Body Injury / Fire / Malicious Damage Claims) 6. Permit, if applicable (Please furnish original for verification) 7. Fitness Certificate, if applicable (Please furnish original for verification) 8. Tax Certificate, if applicable (Please furnish original for verification) 9. Load Challan, if applicable (Please furnish original for verification) 10.Estimate for repairs from the repairer where the vehicle is to be repaired 11.Repair Bills/Invoices 12.Payment receipts after the job is completed
For Theft Claims
1. Duly filled and signed claim form. 2. Original Policy document 3. Original Registration Book / Certificate and Tax Payment Receipt 4. All the sets of Keys / Service Booklet / Warranty Card / Original Purchase Invoice. 5. Police Panchanama / FIR and Final Investigation Report / Non Traceable Report. 6. Acknowledged copy of letter addressed to RTO intimating theft and informing "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 yourself and Financer 10. NOC from the Financer if claim is to be settled in your favour.
* Additional documents required by us if any, will be intimated to you as and when required
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DISCHARGE VOUCHER Claim No. I/We hereby acknowledge having received a sum of Rs. ___________________/- Rupees (_________________________________________________________) from SBI General Insurance Company Ltd. towards full and final settlement of my/our claim upon the said company under Policy No._____________________ in respect of the damage caused to my Vehicle bearing Registration No. ___________________________________ in an accident/theft that occurred on ______/_____/__________ (DD/MM/YYYY)
Place Date:
D D M M Y Y Y Y
Signature of Insured/Claimant Name of Insured/Claimant
