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_____________________ Certificate/Policy No.________________

Tel. No. 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 :___________________________________________
(b) Address for correspondence :
(c) Telephone :

2. THE INSURED VEHICLE

Make & Year Engine No. Registration No.

Chassis No.

(a) Was the vehicle in proper working condition?

(b) For what purpose was the vehicle being used at the time of accident?
(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)

The following questions need be answered in commercial vehicles only:

(a) Registered laden weight :______________________________________
(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 :____________________________________

(b) Age :____________________________________
(c) Address :_____________________________________
(d) Is the Driver
1. Owner :_____________________________________
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 :______________________________________

(h) Issuing Authority :______________________________________
(i) Date of Expiry :______________________________________
(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 :__________________________________________

(b) Place :__________________________________________
(c) Speed of vehicle at the time of accident :__________________________________________
(d) Give a short description of the accident :__________________________________________
(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 :__________________________________________

(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? :_______________________________________

(b) If yes, give full details :_______________________________________

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

(b) Did a Police Constable take particulars of

The accident? :_______________________________________

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

(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.

Date________________200 Signature of the insured_______________