UNITED INDIA INSURANCE COMPANY LIMITED
Registered & Head Office, 24 - Whites Road, Chennai - 600 014

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

CLAIM NUMBER (Office Use)
Pincode
POLICY NUMBER
POLICY PERIOD From To
INSURED NAME
Form No.
Mobile
LOSS DESCRIPTION
CLAIM TYPE
Temporary / Permanent Vehicle types licensed to drive
Driving Licence Number
Licence Issue Date Issuing RTA
Person driving was
VEHICLE TYPE
DRIVER DETAILS
Paid Driver
Date of loss
Hypothecation
Details
Licence valid up to date
Type of license
Provide brief description of accident / theft / occurrence. (Attach separate sheet if required):
Draw a rough sketch of the accident location (Provide Road / Street names along with landmark)
If driver, years of service
Driver Name
Driver Address
Owner
Driver Age (In years)
Others (Specify)
E-Mail
Was driver under influnence of drugs / intoxicants Was driver injured
Place of Accident /
Theft
Model
Accident Theft
Friend / Relative
Licence valid from date
DATE & PLACE OF LOSS
Goods Vehicle Passenger Vehicle Miscellaneous type of Vehicle
INSTRUCTIONS FOR FILLING THE FORM
(a) Complete the form fully without leaving any relevant information. (b) Where check boxes provided tick the appropriate relevant box. (c ) Where multiple boxes, fill one letter per box
STD Code
VEHICLE DETAILS
Registration Number
Registration Date Year of Manufacture
Chassis Number
Engine Number
Make
Landline
Page 2 of 2
Yes No
Kg
Kg Personal use
Kg Hire
Reward
Rallies
Reliability trials
Others (specify)
Temporary Permanent
Local National Inter State Others (specify)
D D / M M / Y Y Y Y
D D / M M / Y Y Y Y
Workshop Contact
Third party involved Yes No (If "Yes", provide additional information)
Third party loss type Death Injury Property Damage
Loss Reported to police Yes No
Date of loss intimation to police D D / M M / Y Y Y Y
D D / M M / Y Y Y Y
Bank Name
IFSC Code Number
Location where vehicle can be
inspected
Address of Workshop / Location
UNITED INDIA INSURANCE COMPANY LIMITED
Registered & Head Office, 24 - Whites Road, Chennai - 600 014.
Account number
Phone
Form No.
INSURED BANK DETAILS
First Information Report Date
FIR / Crime diary number
Police station location
Branch Name
Hospital
Details
MOTOR CLAIM FORM - COMMERCIAL VEHICLE
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
Details of Third party loss
(Attach separate sheet)
Theft of vehicle Theft of accessories (If accessories stolen provide detail as below in a separate sheet)
Address
WORKSHOP
DETAILS
Loss
type
Address
Tractor,Lorry,Jeep (Additional Info) Trailer attached
Workshop Fax
THEFT DETAILS
Rs.
Phone
Third Party Vehicle
Number (If applicable)
Type of Goods carried
Nature of goods carried Hazardous / Non-hazardous
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 thereunder in respect of past or future accidents shall be forfeited.
Date:
Place: Signature of Insured / Claimant
THIRD PARTY LOSS
DETAILS
Name Age
Treatment
Undergone
Yes / No
Make & Brand Serial Number Accessory Accessory Name Insured Accessory IDV
DECLARATION BY INSURED
If No provide reasons
Name
Witness Details
ADDITIONAL LOSS
DETAILS
PURPOSE FOR WHICH VEHICLE
USED AT THE TIME OF LOSS
FIR DETAILS
(Applicable for theft, fire & third party
loss only)
Remarks
Passenger Vehicle
(Additional Info)
Registered carrying capacity
Passengers carried
Permit / Fitness Certificate Details
(For Goods & Passenger vehicle)
Nature of permit
Type of permit
Permit valid for area(s)
Commercial Vehicle
(Additional Info)
Registered laden weight
Registered unladen weight
Weight of goods carried
Workshop Phone
Contact Mobile
Workshop E-mail Loss Estimate
Permit valid up to
Fitness valid up to
Details of other insurance policy
that indemnify this accident.