THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd. & Head Office , New India Building, 87, Mahatma Gandhi Road, Fort, Mumbai - 400 001

MOTOR VEHICLE CLAIM FORM
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS ADMISSION OF ANY LIABILITY

Please answer all required questions fully
Claim No.: Date & Time of Initmation
Policy No. / Cover Note No. Period of insurance
Name of the Insured & Address, e-mail ID & Mobile No. Reporting Branch/Divisional Office
____________________________________________________________________________________________ PIN_________________ e-mail ID_______________ Mobile No. ___________ PAN No. __________________ Bank A/c. Particulars _____________________________ Office Code ____________________________________ Address ________________________________________________________________________________________________________________________ PIN_____________________
DETAILS OF ACCIDENT / THEFT
Date: Time: Place:
FIR No. & Date Charges u/s: Police Station:
In case other Vehicle(s) is/are involved/ responsible, specify vehicle No(s).: Policy details of that Vehicle(s)
Name of the Complainant, who lodged the FIR:
For what purpose was the vehicle being used at the material time?
Brief particulars of the accident
FIR: Specify the reasons for delayed FIR or not lodging an FIR.
Details of other Insurance Policy, if any: