The Oriental Insurance Company Limited

(Incorporated in India, subsidiary of General Insurance Corporation of India)

Regd. Office: Oriental House, P.B. No.7037, A-25/25, Asaf Ali Road, New Delhi- 110 002

MOTOR CLAIM FORM

Div. Br. Office Address_____________________ 211200/31/2025/122137

Certificate/Policy No.________________

Tel. No. 9034644081 2024-06-30 to 2025-06-29

Period of Insurance___________________
Claim No.___________________________

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

Please answer All relevant questions fully

1. INSURED
(a) Name AAKASH SHARMA
:___________________________________________
(b) Address for correspondence : House No. 853 sector 7 urban estate karnal
(c) Telephone : 9034644081

2. THE INSURED VEHICLE

Make & Year Engine No. Registration No.

Chassis No.
MAHINDRA AND MAHINDRA, NMMZD46610, MA1NM2NM1M2D69283 HR05BF0910

(a) Was the vehicle in proper working condition? Yes

(b) For what purpose was the vehicle being used at the time of accident? Personal Use
(c) Was trailer attached?
(d) If a Motor Cycle/scooter
1. Was a side-car attached
2. Was a pillion rider carried

II. ADDITIONAL INFORMATION(COMMERCIAL VEHICLE)

X

The following questions need be answered in commercial vehicles only:

(a) Registered laden weight No
:______________________________________
(b) Unladen Weight :______________________________________
(c) Weight of goods carried/Load Challan No. :_______________________________________
(d) Nature of permit :_______________________________________
(e) Nature of goods carried :_______________________________________
(f) Was the vehicle plying for hire :_______________________________________
(g) If Lorry/Jeep/Tractor, was trailor attached? :_______________________________________
(h) Number of passengers carried :_______________________________________
(i) Number of Passenger permitted :_______________________________________
 3. DIRVER AT THE TIME OF ACCIDENT

(a) Name :____________________________________

AAKASH SHARMA
(b) Age :____________________________________
21/01/1994
(c) Address House No. 853 sector 7 urban estate karnal
:_____________________________________
(d) Is the Driver
1. Owner Yes
:_____________________________________
2. paid driver? :_____________________________________
3. Owner’s relative or friend? :_____________________________________

(e) If paid driver, how long has he been in

your employment :__________________________ ____________

(f) Was he under the influence of intoxication

Liquor or drugs? :______________________________________

(g) Driving Licence Number HR0520120104678

:______________________________________
(h) Issuing Authority Karnal
:______________________________________
(i) Date of Expiry :______________________________________
11/04/32
(j) Was the licence temporary/permanent :______________________________________
(k) Details of endorsement/suspension, if any :_______________________________________
(l) Has he been involved in any accident before?:_______________________________________
(m) Has he been charged by the policy?If so, Why?:____________________________________

4. OTHER INSURANCE

Details of other insurance Policies indemnifying you in respect of this accident

5. DETAILS OF ACCIDENT

(a) Date and Time 22/11/2024, 15:00

:__________________________________________
(b) Place House No. 853 sector 7 urban estate karnal
:__________________________________________
(c) Speed of vehicle at the time of accident :__________________________________________
(d) Give a short description of the accident Ref Below (Page 4)
:__________________________________________
(e) If any third party was responsible for this
accident give the name and address :__________________________________________

6. DAMAGE TO INSURED VEHICLE

(a) Full details of damage :__________________________________________

(b) Estimated cost of repairs :__________________________________________
(c) When and where can the damaged vehicle
be inspected :__________________________________________

7. THIRD PARTY INJURY/PROPERTY DAMAGE

(a) Name :__________________________________________

No
(b) Address :__________________________________________
(c) Full Details of personal injury sustained :__________________________________________
(d) Name and address of any person/hospital
giving medical attention to injured person :__________________________________________
(e) Full details of property damaged :__________________________________________
(f) Has notice of any claim been given to you? :__________________________________________
 8. INJURY TO DRIVER/OCCUPANT

(a) Was driver/any occupant injured? :_______________________________________

No
(b) If yes, give full details :_______________________________________

9. WITNESS
(a) Give names and addresses of passengers/other
Witness, if any Diksha, 9053789659
:______________________________________

(b) Did a Police Constable take particulars of

The accident? :_______________________________________

(c) Was accident reported to Police? If not,Why? :_______________________________________

Not Applicable

(d) If yes, to which Police Station? :_______________________________________

(e) Date and Diary No. :_______________________________________

10. THEFT

(a) Date and Time :_____________________________________

(b) Place :_______________________________________
(c) What was stolen? :_______________________________________
(d) Estimated cost of replacement? :_______________________________________
(e) By whom discovered and reported? :_______________________________________
(f) Has theft been reported to Police? :_______________________________________
(g) When? :_______________________________________
(h) Which Policy Station? :_______________________________________
(i) C.R. diary Number :_______________________________________

______________________________________________________________________________________

I/we the above named do hereby, to the best of my/our knowledge and belief, warrant the truth of the
foregoing statement every respect and 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 of any suppression or
concealment, the Policy shall be void and all rights to receive thereunder in respect of part or future
accident shall be forfeited.

04/12/2024
Date________________200 Signature of the insured_______________
Accident Description: My car touched with the dumper of blue colour due to which left headlamp of my c
ar along with front bumper got damaged.