Lit eoan Gar nan Company ned | . Soe orton 40013 Liberty Videocon Saas era Pa ava Ganeval owe ERE ctngnSeetet MOTOR INSURANCE CLAIM FORM PRIVATE CAR/TWO WHEELER ISSUANCE OF THIS CLAIM FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY ‘Glin Form oe fled In canal ters and sora byte Insured “a damaged vohce rust bo partes a sae plco aval any subsaquent bss he. Pons soot the document a mentoned on ie rovers of forme Please dont losveanyclurn unanswered, Menton “NI Hn appeal, Ifanyintrmatons nol ely avaible please donot day te pach of hs form and oer parts maybe sent ate Pokey Number : oO Pv o aura 77 el E77 Name of te sued sions a Contac umber Phane_STO Code mal 1 ate Time ANIM ection I ov [TTT TTTITTT TTT) sate [ Pin ose I Ras Type Express way [Nala Site Highway Ci Town Reb 1 Distiet Road Others. ‘Speed atthe tine of accident wn Dar [PartalThetepecy This Party Death Ted Panty ury CTA Pay Properly Damage © Parson Aceidert Purpose for whe vile was ng uae a tei of ect te, ‘umber tpesonsweetog [[ |] Ary oter vedi invneg tn case tet ay inte posession ot? vere CTT LI Contac ro. HO Tana ine Contact Dea of pesos te Lacaton ettona wih nated Comact Number: Phone STD Code Email > Typo of Loss Desore Cae of Loss/Damage / Acide Pease aw a shel of set of scldnt & desebe poston of vehicle a he tne a accent Indu nearby landmarks FIRIDOR GDR ary: Yes CNS Maal (eases Potee FIR GDR DOR eta No: ate Pole Siaton name I ow CTT SateLivery Videocon General insurance Company Limits {tte or ower Sona Spe ar ot ese 018 Liberty Videocon General insurance Pana sat 28 e700 ta Faw “902 6700 Ta6 Ena carodoarocen com Fg, No oko chassis No, cobur aio of Regsvaton \evole Gass [7 Two Wheeler (1 PM.Car otar (pec) Eraino No. RTO Jureictor PEE Name tomer [T daw orsen [TT]/ E/E) Retatoraip wise LLL come: ou OF Cualiaton: Ti Below Toh TIO Pass Bh Pase F Greduson PS Comact Number: Prone STD Code No. E-malid ‘ening Leena Na Date of sue ate of Exary tssuing RTO type ottense: Permanent Temporary Cass: IM.Cyeh WIG LIMACyeleWotS LILMV Transpo Li NonTranspot LING“ Passorger ‘Special Endorsements, any IE, THIRD PARTY DEATHINJURYIPERSONAL ACCIDENT DETAILS (aac aonal sheet, #remured) [| Name ofperson | Whether | Address | Contacto. | DeativType [Name of Hospital| Name of | Detals of Any Legal Ie, Passenger ot lnury”_ | where aamited | Attending Doctor| Court Ntice ecawed dy aber intormation We. he above nara, do hereby. th best of mycurknowodgo and bela, warant ta ruth ofthe foregoing satomonis in avery respec and lve agree that Ive have made or ay further declaration, th Compary tay equreinrespct fhe sald acd, shall make ary aloo aden satin. o any ipprosean ar concealment. the Company may fof the erie dam an he Poley shall be nll and vod, and al igh to recover here unser i expect pat bortarelonslacedants sat be otatea We have tached thet of documents wh this kin Form an have undersond the ete raqurorent ob file for adminstaton of hie lnm andthe Campa shal a beheld response foray delay salman of cian du onan taliant t regemants nung tne documents as mentioned inthe ci for |W agree t prove atonal information ad atonal documentation to he Company, Frequed We futher authors the Company lo access my/our isormaton eleven tothe Claim under process Pico co Sipatee Date Name of nse Cima: ForAcedent Claims For Theft Caime 1. Pat fnsurance Pale ! Cover Nate copy 1. ignal Poe document 2. Copy of Repsvaton Book, Tax Rezo 2. Orenal Repsvaton Book! Conical ad Tex Payment Rocapt {Please tumsn orignal fr vesteaton) | Althoaoe of oye Soros Booket/ Warranty Card! Orginal Purchase Invoice 43. Copy af Motor Orving Liens! the pesonerving the void at | & Pace Panchanama FIR and Final Repel Non Traceable Report thetie of arent (Please lumish oral fo vention) 55 Aeksowedged copy of le” edaressed ta RTO manag tel 2 orig 4, Polos Panchanama FR SNONUSE* 5. Estmaieofropars fom the reparerwherthe veil is tobe | 6, Form 28,29 and 20 sgres bythe inured and Form 35 sgnedby te Financier ‘epared 7. Subogaton cum spec Power ot Aomey 65, Ropar Bilswcices and payment ecaipts ater the ob is completed | & Cangent awards apeed cam serie vals om youself and Financier 7. Discharge Voucher NOC fram the Fiance clam tobe ested you avout 10, Indonmty bona & charge voucher = alone! docueisrequred by us an, wi be sted yu 8 and when requ