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UNITED INDIA INSURANCE CO. LTD.

Regd. & Head Office : 24, Whites Road, Chennai. Visit us at www.uiic.co.in

MOTOR CLAIM FORM – TWO WHEELER / PRIVATE CAR

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
Instructions for filling the form.
(a) Complete all relevant details fully (b) Where boxes are provided, enter one letter per box (c) Where check boxes are provided indicate selection using tick
mark.

CLAIM NUMBER
(For Office Use only)

POLICY NUMBER

POLICY PERIOD From To

INSURED NAME Sum Insured: Rs

INSURED ADDRESS
PINCODE Mobile No
STD Code Landline
E-Mail

REGISTRATION NO
CHASSIS NUMBER
VEHICLE DETAILS ENGINE NUMBER
MAKE MODEL
HYP/HPA IF ANY

DATE OF LOSS
TIME OF LOSS
DATE & PLACE OF LOSS
Vill/Town
PLACE OF ACCIDENT/THEFT
Mdl: Dist:

Driver Name / Age / Relation with the Insured

DRIVER ADDRESS

DRIVER DETAILS DRIVING LICENSE NO

DATE OF ISSUE DATE OF EXPIRY
Was driver under
Was driver
influence of drugs / YES NO YES NO
injured
intoxicants

Provide brief description of accident/theft/occurrence (attach separate sheet if required)

(provide a rough sketch of accident location)

ACCIENT DETAILS

Two wheeler (Additional information) Pillion Rider carried Yes No

Private Car/Two wheeler No of occupants carried

VNS BO MNCL 1
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UNITED INDIA INSURANCE CO. LTD.
Regd. & Head Office : 24, Whites Road, Chennai. Visit us at www.uiic.co.in

Address of workshop
WORKSHOP DETAILS
Workshop contact Estimated loss
Workshop Mobile Workshop Phone
Workshop Fax Workshop E-mail

Theft of vehicle Theft of Accessories

(If accessories stolen provide detail as below in a separate sheet)
THEFT DETAILS Make & Serial
Accessory Name Accessory Insured Accessory IDV
Brand Number
Yes/No Rs

Accident/Theft reported to If not provide

FIR DETAILS Yes No
Police reasons
(Applicable to theft, fire,
Date of reporting to police
loss of personal effects &
Name of Police Station
third party loss only)
FIR NO & DATE

Third party
Yes No If Yes, provide additional information
involved
Third party
Death Injury Property damage
loss type
Driver injured
Third
THIRD party
Details of Loss Treatment Hospital
PARTY LOSS Name Age Address Phone vehicle Remarks
Third party type undergone details
DETAILS no (if
loss (Attach
applicable
separate sheet)

Name Address Phone No

Witness details

Courtesy car facility If Yes, expected repair

Yes No
availed (Private Car only) completion date
ADD ON
Medical expenses
COVERS Yes No Likely expenses
required (Private car only)
(if applicable)
Loss of personal effects List items lost with value as a separate sheet – FIR
(Private car only) MANDATORY

Account Number
INSURED
BANK BANK NAME BRANCH
DETAILS IFSC CODE
( 9 Digits)

DECLARATION BY INSURED

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 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 rights to
recover there under in respect of past or future accidents shall be forfeited.

Place:
Date :
Signature of Insured / Claimant.

VNS BO MNCL 2