Claim Form
Private Car Long Term Package Policy
Claim No.:
A. Policy Holder/Claimant Details
Claim No.: Period of From: To
Insurance :
Nameas per Policy :
Claimant Name :
Address :
Pin code : State :
Email : Phone No.:
Mobile No.: Fax No. :
B. Vehicle Details
Registration No. : Engine No. :
Chassis No. : Make : Model :
Date of Registration : Class of vehicle Private Commercial Two Wheeler
Financier’s interest
if any :
C. Loss Details
Accident Theft
Date of Occurrence: Time of Occurrence : A.M. / P.M. Speed:
Km/Hr. Current location : Place of Occurrence:
Nature& weight of goods carried at the
time of accident (Commercial Vehicle):
Short description of loss :
(please attach separate sheet if needed)
No. of people travelling in the insured:
vehicle at the time of Loss
Purpose for which vehicle was:
being used at the time of Loss
Is loss reported to Police? Yes No Police Station :
Diary / FIR No. : Is loss reported to Fire Brigade? Yes No
Fire Station : ReferenceNo. :
D. Details Of Driver At The Material Time Of Accident
Name of Driver :
Version: 1.0 July 2024
Contact No.: Relationship with Insured :
SBI General Insurance Company Limited. Registered and Corporate O�ce: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai 400 099|CIN:
U66000MH2009PLC190546 | Toll free: 18001021111 | [email protected] | www.sbigeneral.in | For more details on the risk factor, terms, and conditions,
please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale| SBI Logo displayed belongs to State Bank of India and used by SBI General
Insurance Company Limited under license | IRDAI Reg No: 144 | Private Car Long Term Package Policy, UIN: IRDAN144RPMT0022V01202425 | SBI General Insurance1
and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products
Call (Toll Free) | 18001021111 | [email protected] | www.sbigeneral.in 1
Driving License No.: License Type: Permanent Learner
Issuing RTO :
Class of Vehicle authorized to drive:
Issue Date : Expiry Date :
E. Direct Fund Transfer/Eft Mandate Form. Please enclose a cancelled Cheque leaf along with the Claim Form (Mandatory)
Bank Name : Branch :
City : State : IFSC Code :
MICR code : Payee Account No. :
Name of Payee :
F. Garage / Workshop Details (Note: Please do not dismantle the vehicle before survey)
Nameof Garage/Workshop :
Contact Person : Contact No.:
Address :
Estimated Loss Amount :
G. Other Insurance Details
If there is any other insurance policy indemnifying you in respect this accident? YES NO If' Yes', please provide details
Name of Insurer :
Policy No :
Period of Insurance :
H. Occupants / Passenger / Third Party – Injury/Death Details
Occupant/Passenger
Sr. No. Name Address Contact No. Age travelling in what capacity Nature of injury
Third party property damage detail (Also including other vehicle if any involved) - In case of additional information please attach a
separate sheet
I. Witness Details If Any
Sr. No. Name Address Contact No.
SBI General Insurance Company Limited. Registered and Corporate O�ce: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai 400 099|CIN:
U66000MH2009PLC190546 | Toll free: 18001021111 | [email protected] | www.sbigeneral.in | For more details on the risk factor, terms, and conditions,
please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale| SBI Logo displayed belongs to State Bank of India and used by SBI General
Insurance Company Limited under license | IRDAI Reg No: 144 | Private Car Long Term Package Policy, UIN: IRDAN144RPMT0022V01202425 | SBI General Insurance1
and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products
Call (Toll Free) | 18001021111 | [email protected] | www.sbigeneral.in 2
J. 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 ful�lled for administration of this claim and the Company shall not be held responsible for any delay in settlement of claim due
to non-ful�llment of requirements including the documents as mentioned in the claim form. I/we agree to provide additional
information and additional documents to the Company, if required.
I/We hereby extend my/our consent to the Company for sharing my/our personal data with State Bank Group entities for speci�c
purpose of availing services o�ered by State Bank Group(please strike this clause in case you do not wish to disclose the personal
data)
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.
K. List Of Indicative Documents
For Accident Claims For Theft Claims
Duly �lled and signed claim form. Duly �lled and signed claim form.
Copy of Registration Book (Please furnish original for Original Policy document
veri�cation)
Copy of Motor Driving License of the person driving the Original Registration Book / Certi�cate, Permit, Fitness
vehicle at the time of accident (Please furnish original for Certi�cate, Tax Certi�cate & Load Challan.
veri�cation)
Police Panchnama/FIR (In case of Third Party property Police Panchnama / FIR
damage / Death / Body Injury / Fire / Malicious Damage
Claims)
Estimate for repairs from repairer where vehicle is to be Final Investigation Report from the magistrate’s court
repaired under section 173 Cr. P C / Non Traceable Report.
All the sets of Keys / Service Booklet / Warranty Card /
Repair Bills/Invoices after the jobs is completed
Original purchase invoice
Acknowledged copy of letter addressed to RTO
Payment receipts after the jobs is completed
intimating theft and informing "NON-USE" of vehicle
KYC/AML for losses above 1 Lakh Form 28, 29 and 30 signed by the insured and Form 35
signed by the Financer, as the case may be, undated and
Additional documents in case commercial vehicle blank
Permit, Fitness Certi�cate, Tax Certi�cate & Load Challan, Letter of Undertaking, Subrogation & Discharge Voucher
(Please furnish original for veri�cation)
Consent towards agreed claim settlement value from
yourself and Financier.
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
SBI General Insurance Company Limited. Registered and Corporate O�ce: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai 400 099|CIN:
U66000MH2009PLC190546 | Toll free: 18001021111 | [email protected] | www.sbigeneral.in | For more details on the risk factor, terms, and conditions,
please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale| SBI Logo displayed belongs to State Bank of India and used by SBI General
Insurance Company Limited under license | IRDAI Reg No: 144 | Private Car Long Term Package Policy, UIN: IRDAN144RPMT0022V01202425 | SBI General Insurance
and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products
Call (Toll Free) | 18001021111 | [email protected] | www.sbigeneral.in 3
Satisfaction Note
(To be obtained from Insured, where payment is being made to the repairer)
Claim Number: Policy Number:
Vehicle Number:
I inspected my car repaired by M/s.
I hereby con�rm that the damages claimed by me under the above mentioned claim have been repaired to my utmost Satisfaction.
I request you to pay the claim amount Rs. directly to the repairer so that I can take Delivery of my car by paying
Depreciation / extra work amount of Rs. to them.
I accept the settlement to be full & �nal and discharge SBI General Insurance Company Limited of all liabilities arising out of claim.
Place: Name of Insured/Claimant:
Date:
Signature of Insured/Claimant:
(Rubber stamp in case of Insured is a �rm)
Discharge Voucher
Claim No.:
I/We hereby acknowledge having received a sum of Rs. /- Rupees ( )
From SBI General Insurance Company Ltd. towards full and �nal 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
Place:
Date: Signature of Insured/Claimant
(Rubber stamp in case of Insured is a �rm)
SBI General Insurance Company Limited. Registered and Corporate O�ce: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai 400 099|CIN:
U66000MH2009PLC190546 | Toll free: 18001021111 | [email protected] | www.sbigeneral.in | For more details on the risk factor, terms, and conditions,
please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale| SBI Logo displayed belongs to State Bank of India and used by SBI General
Insurance Company Limited under license | IRDAI Reg No: 144 | Private Car Long Term Package Policy, UIN: IRDAN144RPMT0022V01202425 | SBI General Insurance
and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products
Call (Toll Free) | 18001021111 | [email protected] | www.sbigeneral.in 4
