Intimation Cum Preliminary Claim Form – Auto Policy
Please keep the information handy before ringing up the 24X7 call center at
1800-119966 or SMS CLAIMS to 58888
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY.
PLEASE SIGN ON BOTH SIDES OF CLAIM FORM. DO NOT LEAVE ANY COLUMN UNANSWERED.
Claim No. ____________________ Policy no. ___________________
Vehicle No. ___________________ Eng No._________________________ Chassis No.__________________
INSURED/CLAIMANT NAME: _____________________________________email:____________________
Address: ___________________________________________________________________________________________
_________________________________________________________________City_______________Pin_____________
Mob ____________________________ Tel Res _________________________ Tel off ____________________________
Time & Date of Accident / Occurrence Hrs D D M M Y Y Y Y Place of Accident
Type of Loss (details overleaf) OWN DAMAGE THIRD PARTY Bodily Injury Property
Damage Short Description of Accident/Incidence (Sketch overleaf) ____________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
To be filled only in case of commercial vehicle
Permit valid upto __________________________________ Fitness valid upto________________________________
Load carried at the time of accident ____________________ No. of passengers carried at the time of accident ________
Police FIR no. (lodged if any) ____________________________Police Station______________________
Details of the driver at the subject time of accident
Name _____________________________________________________ Age _____ Occupation_________________
Driver is Owner Paid Driver Relative/ Friend
Driving License No. _________________________________ Badge no ________________________
Effective for (type of vehicles)_____________________________Effective upto:______________________________
Please enclose self – certified copies of Registration Certificate, Driving License, Fitness & Permit Certificate (by the insured as applicable). Also please
enclose copies of Police Report and Fire Brigade Report, if lodged.
DECLARATION
I/We agree to provide additional information to the Company, if required. I/We the above named, do hereby, to the best of my/our knowledge and
belief, warrant the truth of the foregoing statement in every respect, and if I/We have made, or in any further declaration the Company may require in
respect of the said accident, shall make any false or fraudulent statement, or any suppression or concealment, the policy shall be void and all rights to
recover thereunder in respect of past or future accidents shall be forfeited.
I understand that the Company reserves the right of verification (*) of facts and documents relating to the policy and claim.
Place
Date: D D M M Y Y Y Y Signature of the Insured
CLAIMS DEPARTMENT
Tata AIG General Insurance Company Ltd.
Ahura Centre, 4th Floor, 82, Mahakali Caves Road, Andheri (E), Mumbai-400093 P.T.O
DETAILS OF DEATH/INJURY/PROPERTY DAMAGE TO THIRD PARTIES/OCCUPANTS/DRIVER
Sr Name of Address Contact No. Type of Injury/ Name of the Doctor Any Legal/Court
no Third Party/Occupant/Driver (Village/Town) Damage Hospital where Attending Notice Recd.
admitted
N.B. Please attach additional sheet with full particulars, if needed.
Show how the accident occurred by using this diagram
Give street names, direction and location of objects concerned
EFT details
1 Payee Name / Insured Name
2 Permanent Account Number (PAN)
3 Particulars of Bank Account
A. Name of the Bank
B. Name of the Branch
C Address
D. City Name and Pin No.
E. IFSC Code
F Type of Account Saving/Current
G Account Number
4 Payee’s email id
DECLARATION
I/We agree to provide additional information to the Company, if required. I/We the above named, do hereby, to the best of my/our knowledge and
belief, warrant the truth of the foregoing statement in every respect, and if I/We have made, or in any further declaration the Company may require in
respect of the said accident, shall make any false or fraudulent statement, or any suppression or concealment, the policy shall be void and all rights to
recover thereunder in respect of past or future accidents shall be forfeited.
I understand that the Company reserves the right of verification (*) of facts and documents relating to the policy and claim.
Place
Date: D D M M Y Y Y Y Signature of the Insured
CLAIMS DEPARTMENT
Tata AIG General Insurance Company Ltd.
Ahura Centre, 4th Floor, 82, Mahakali Caves Road, Andheri (E), Mumbai-400093. Fax: +91 22 56938171
(Regd. Office : Peninsula Corporate Park, Nicholas Piramal Towers,9 th Floor,G K Marg, Lower Parel Mumbai - 400013)
