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IFFCO-TOKIO GENERAL INSURANCE COMPANY LTD. Regd. ce: 4, Neu Place, New Dei - 11019 =) 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

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