MOTOR INSURANCE CLAIM FORM (PAYD)
ISSUE OF THIS FORM DOES NOT IMPLY ACCEPTANCE OF LIABILITY.
PLEASE GIVE ALL THE DETAILS ASKED FOR IN THE CLAIM FORM. CLAIM FORM TO BE FILLED AND SIGNED IN BY THE INSURED ONLY.
Policy No _________________________________ Claim No _____________________________________
Registration No __________ Engine No ____________ Chassis No _____________ Odometer___________
1) INSURED DETAILS
Name_________________________________________________________________________________________
Address_______________________________________________________________________________________
Mobile No._____________________________________ E-Mail Id________________________________________
Details of other existing Insurance policy (ies) in respect of this accident_____________________________________
2) LOSS DETAILS
Date & Time of Accident/ Occurrence _____________________Place of Loss________________________________
Type of Loss Damage Theft Third Party
Short Description of Accident/ Incident_______________________________________________________________
______________________________________________________________________________________________
___________________________________________Estimated Cost of Repairs______________________________
Odometer reading at the time of taking the policy______________
Odometer reading during the accident____________________
3) DRIVER DETAILS
Name____________________________________________________________________Age__________________
Is Driver: Owner Paid Driver Relative/Friend
Driving License No. ______________________________Valid up to_______________________________________
Authorised to drive______________________________ Issuing Authority__________________________________
4) INJURY/DEATH DETAILS & POLICE REPORT
Police Report Lodged Yes No
If yes, FIR/GD No.___________________________________ Police Station Name____________________________
Death/Injury to any occupant / Third Party (others) Yes No
Third Party Property Damage Yes No
Details in case of Death and/or Injury to Third Party/Occupants/Driver or damage to property:____________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5) DECLARATION
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 I/We agree that 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 right to recover there-under 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 policy and the claim.
Date _________________Place _______________________ Signature of the Insured _____________________
National Insurance Company Limited,
Registered Office:- Premises No. 18-0374, Plot no.CBD-81, New Town, Kolkata-700156
