IFFCO-TOKIO GENERAL INSURANCE COMPANY LTD.
Regd. ce: 4, Neu Place, New Dei - 11019
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MOTOR CLAIM FORM cee ene
[Policy No. Period of insurance From To Claim No.
insured Particulars Insured's representative incase of corporates
Name Name
Designation|
Address,
E-mail
[cny [Phones, [Fax Mobile No.
Vehicle particulars
Make Year of Mig. engine No.[Ghasis No] Registration No.
Driver Particulars (Driver at the subject time of accident)
Is Driver a Paid
Name. ‘Age of the Driver Employee?
IDL No. Valid upto Yes/No
issuing
authority Vala for (ype of vehice
‘Accident particulars
Place of accident [bateaTing)
Have you reported to the Police/Fire brigade? [YESINO (lf Yes attach FIFVFite brigade report copy)
[Short description of the accidenttheft
[Type of loss/damage
(Own damage (amount in Rs.) {Third Party] Bodily injury
Property Damge
[Estimate of Damage
(pl. attach copy of the
estimate)
cred persons wore treated)
Details of third party Injary/ Property damage T any
(tush tw name and address of tho Doctor Hospital where
IName and address of the Workshop for repairs
(PL. furnish the name of contact person in the workshop)
[Additional Information in case of Commercial vehicle
[Registered Laden weight
Fitness details
[Laden Weight
Was a traller attached?
YESINO
(Weight of goods carried
[Passenger Carrying capacity
[Type/Nature of permit
INo. of passengers carried
Place
Date
A. attach copies of the permil/tipsheet / List of passengers. Attach addtional sheets Ifthe space povided Is not adequate
|/ We declare that to the best of my /our knowledge and belief, the above particulars are true, | also agree to
provide any further information and documents that may be required,
Name & Signature of the Insured
The Issuance ofthis form is not to be taken as an admission of fabiliy
|FFCO-TOKIO GENERAL INSURANCE CO. LTD.
Ph OM2258866, 235335 Fax: OD ZZISUSS El -cceounG.con
{on Yr OF OA ERS ETLER EOE LNT WOT TKO WRENCH FRE NSN TD &
CIPI SME CENT SOUM GC bing been Geman oop soe
TOKIO MARINE,
NICHIDO