NATIONAL INSURANCE COMPANY LIMITED
(Regd. Office : 3, Middleton Street, Calcutta – 700 071)
MOTOR CLAIM FORM

· Issue of this form is not to be taken as an admission of liability.
· To avoid unnecessary delay, correspondence and trouble, this form
should be returned within 7 days of its issue to the Policy Issuing
Office with all relevant questions fully answered.
· Ticks or dashes will not suffice.
Address for Communication :
Policy/Certificate/Cover Note No.:
Period of Insurance :
Claim No. :
Agents Code :
1. THE INSURED
a) Name in full
__________________________________________________________________________________
b) Address for Correspondence
_____________________________________________________________________
c) Telephone Number, if any _______________________________________________
__________________________________________________________________________________________________________
2. THE INSURED VEHICLE
a) Particulars of Vehicle
__________________________________________________________________________
Make Year of Manufacture Engine No. Chasis No. Registration No.
b) Was the vehicle in proper working condition ?
c) For what purpose was the vehicle being used at
the time of accident ?
d) Was a trailer attached ?
Yes / No _______________
Yes / No _______________
The following additional information is required in case of Motor Cycle / Scooter :
e) Was a side Car attached ? Yes / No
f) Was a pillion rider carried ? Yes / No
The following additional questions need to be answered in case of commercial vehicles :
g) Registered laden weight :
____________________________________________________________
h) Unladen weight :
____________________________________________________________
i) Weight of goods carried :
____________________________________________________________
j) Nature of Permit :
____________________________________________________________
k) Nature of goods carried :
____________________________________________________________
l) Was the vehicle plying for hire : Yes / No
____________________________
m) Number of passengers carried :
____________________________________________________________
n) Number of passengers permitted :
____________________________________________________________
3. DRIVER 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
Intoxicating 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 policy/ies indemnifying
You in respect of this accident
___________________________________________________________________________
________________________________________________________________________________________________
5. DETAILS OF ACCIDENT
a) Date of Time
Date Month Year Time
A.M. P.M.
b) Place
________________________________________________________________________________________
_____
c) Speed of your vehicle at the time of accident
______________________________________________________________
d) Give a short description of the accident
__________________________________________________________________
e) If any third party was responsible for the
Accident, give 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 & 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. WITNESSES
a) Give names and address of passengers /
Other witnesses, 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) C.R. Diary number ___________________________________________________________________
________________________________________________________________________________________________
10. THEFT
a) Date & Time : ______________________________________________
b) Place : ______________________________________________
c) What was stolen ? (If parts only give full
Details in separate sheet) : ______________________________________________
d) Estimated cost of replacement : ______________________________________________
e) By whom discovered and reported ? : ______________________________________________
f) Was theft been reported to police ? : ______________________________________________
g) When : ______________________________________________
h) 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 in every respect and I/We agree that if I/We have made or in any further declaration the company
may require in respect of the said accident, shall make any false or fradulent statement or any suppression or
concealment the policy shall be void and all right to recover thereunder in respect of past or future accidents shall be
forfieted.
Date Signature of the Insured
Skd./ motor claim