Your insurance policy
now at your nger tips!
MOTOR INSURANCE - CLAIM FORM Download
m-Chatra app
FOR OFFICE USE ONLY Date of inward D D M M Y Y Y Y Claim Number
IMPORTANT
To ensure priority processing, please complete all sections in CAPITAL letters. Please tick in the relevant boxes. Please attach additional sheet(s), if required, to answer a
question with more detail.
The issuance of this form is not to be taken as an admission of liability. Verification of original vehicle registration certificate and driving licence along with submission of duly-
filled in claim form (signed only by the insured) is a must for arranging survey. Please provide any additional document/information if required.
Page 2 to be filled up if there is any third party injury, death or property damage. If it is not filled, it will be deemed that there are no such consequences in the said accident.
DETAILS OF INSURED PERSON & VEHICLE
Date of submisson Policy No./Cover Note No.
D D M M Y Y Y Y
of Claim Form
Insured Name
Address for Communication
Pincode
Mobile Number PAN Number
Email
Details of other existing insurance policies for the vehicle ...................................................................................................................................................................
Registration No. Is there any nancier's interest on the insured vehicle Yes No
of insured vehicle
DETAILS OF ACCIDENT/LOSS
Date and Time of Accident/Loss D D M M Y Y Y Y H H M M am/pm Place of Accident/Loss: ....................................................
Narration of cause of Accident/Loss: (Do not state police report attached or as per police report )
Purpose of use of vehicle at the time of Accident/Loss ..........................................................................................................................................................................
Nature and weight of goods carried (for Goods Carrying Vehicle) .......................................................................................................................................................
Number of occupants in the vehicle at the time of accident
Has the incident been reported to the Police Yes No
If yes, FIR/GD Entry No. ......................................................... Date D D M M Y Y Y Y Police Station................................................
DETAILS OF DRIVER
Name of driver at time of accident
Date of birth of driver D D M M Y Y Y Y Driving License No.
Relationship of driver to insured Self Relative Friend Paid Driver Others ......................................................................................
(Please specify)
Page 1 of 2
DETAILS OF THIRD PARTY
Has the accident resulted in any death, injury or property damage belonging to a third party? Yes No
Details of death of or injury to persons travelling in the insured vehicle
In what capacity* Death Injury
S. No. Name Age Gender Nature of injury etc.
he/she travelled (Please tick )
1.
2.
3.
4.
5.
*Driver/Friend/Relative/Employee/Passenger/Others
Details of death of or injury to persons outside the insured vehicle
Contact Death Injury
S. No. Name Age Gender Nature of injury etc.
details if any (Please tick )
1.
2.
3.
4.
5.
Has notice of a third party claim been served to you? Yes No If Yes, please enclose with this form.
Please specify any details of witnesses to the accident ...........................................................................................................................................................................
Third party property damage details: (including details of other vehicle, if any involved)
I/We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. I/We agree to provide any further
information or documents or assistance that may be required for processing my/our claim.
Note that the contact details such as phone number and email you have provided will be updated in our system along with your policy details. We will reach you
through this mobile number and/or email for all communication henceforth.
Date D D M M Y Y Y Y Place ____________________________ Signature of the insured _____________________________________
(Affix seal if vehicle is owned by a Company along with authorized signature)
Please refer to the claim procedure for your vehicle damage (Own Damage) claims given below or visit www.royalsundaram.in
CLAIMS PROCEDURE (Please read carefully and understand the process of a motor claim. This is only a brief and not a detail/complete process)
Claim should be intimated to us immediately with the policy particulars.
Do not repair the vehicle before survey.
Survey will be arranged on receipt of claim intimation and submission of detailed estimate of repairs from the repairer.
Original Registration Certi cate (RC)/Driving Licence (DL) may need to be submitted to us for veri cation and return.
Claim form duly lled and signed only by insured as named in policy schedule must be submitted to the repairer/surveyor.
FIR to be led wherever third party injury/death/property damage is involved. A copy is to be submitted to the insurance company.
Company may ask for additional documents and/or clari cation/information, depending on the requirement of the claim.
Cashless facility will be arranged if required documents are in order, claim is admissible and the facility is available at the place of repair.
Based on surveyors instructions, vehicle to be produced for re-inspection on completion of repair works.
Original bill along with satisfaction voucher for cashless claims is required for processing the claim.
For non-cashless claims (reimbursement claims) original cash bill or invoice with cash receipt is required for processing the claim.
A detailed theft claim process letter will be sent to your communication address (mentioned in the policy/claim form) through registered post after intimation of theft claim.
For claim status enquiries, you may please contact the helpline number 1860 425 0000
Your insurance policy
now at your nger tips!
Royal Sundaram General Insurance Co. Limited
Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai - 600 002. Download
IRDAI Registration No.102 | CIN:U67200TN2000PLC045611 m-Chatra app
1860 425 0000
[email protected] www.royalsundaram.in
PR19095/MAY19/V6
Page 2 of 2
