IRDA Registration Number - 137 SHRIRAM RKC es BE INSURED... REST ASSURED The issue of this form is not an admission of liability. Please fllin all columns of the claim form. Attach Separate Sheet ifthe spaceis not sufficient. ge yaa of oe @e) or sel erfMer Geo eM aT As OY] |VAT eta MUA} we orers HV | TE S ara A aiersT A wie vig wd 21 Pate Peek Claim Number: Policy Number insured Gra THAR difereh aay Pa Period of insurance: (From) (To) ar ah era ara (wa a) («a 0) Telephone Number (Landline) (Mobile) a ‘Address (where al correspondence be done regarding this claim) var Vehi Regd. No Date of Registration Registration Authority aoaga wer iattorer Fete often sift Type of Fuel Cor of Vehicle Make & Model rt 1 WOR area oe Registered Owner Transfer of Ownership (if any) aohtea afer Hnferort Go wT RAAHARIT Engine No Chassis No ort a Rv Type of Body Class of Vehicle Seating Capacity ad or ver ‘aes BI WHE 469 Oa Previous Insurer Name & Policy Number | Expiry Date of Previous Insurer Policy | Claim History in Previous Insurer's Policy ag nr or a HPS 1g fee AY eo aed ifaeeh we rad or Rear ia BPA Date of Accidenl/Theft Time ger /ant a are a Place of Accident/Theft Estimated Loss Amount gees / ate or eet separ oat ae Name and Address of the Workshop with Phone No a@rbarent Br aM ¢ vat Ya ect 4 Purpose for which Vehicle was being used at the time of Accident/ Theft guear/ att S wre met or orate fies gator + fery fora oT eet eT ‘Number of Person Traveling tthe Time of Accident Theft glen /at @ ara ue ates A gat waa Bie FIR No. (if reported to Police) & Name of Police Staton eoomgare of ore amd A RUA aN) ge yer eM wr oT Circumstances & Cause of Accident/Theft gder/ ae at afeReral ys werPR ee Fitness Certificate No Expiry Date fete gure va a ara BPR Carrying Capacity (good vehicle) Details of Load Challan art eran (ara are") ats ara a Rawr Passenger Canying Capacity No of Passengers at the time of accident wartt err glen & wa ga watt A eeu PRC eee ee Report if accident has resulted in injury/death to third party. gttear @ orem qifta ver at ate / eq wr Rawr : Detail of injury / ae a7 FART] Your Employee /srwenr afurel Name |i Address | at (MajoriMinorDeath) (esiNo) ‘Name of the Hospital where treatment done fierce wrt wet wera fra Tar Estimated Third Party (If not your Own) Properly Damaged (IFAny) aot uer @) segmPrer eferree euler Repisajon No. fer vail responsi or acon geen & fare Rieter sea ares ar doh a Pann foams Driver Name ‘Adress with Telephone Number eet 1 AT aor yd Seto Driving License No Effective From To wre argh eer oad wae Registered Owner “Type of conse Learning ‘Permanent wohea fee anda BI THN oreerrg / eg ‘Authorized to drive the types of vehicles fia wore @ are war @ fay airqa 21 Detals of Endorsement Suspension, any "peters Preten wr ser a hy eh FAN Sade ee oe On Bank Account Holder Name Mr arden @T 5TH Father/Husband Name in Bank Account te ard F Aen / aie oT ae Mr Bank Name @@ or am Branch Name S1re1 ®t =e Branch Address Ral &1 Wat City wee State a9 Account Number «arate IFSC Code are. en gaat He Account Type Td =r WHR | conten that | had proposed for insurance of my cited vehicle which is evidenced by the Policy issued by Shriram General ngurance Company Ltd. Conf thatall information furnished to the Company though the proposal and any other interactions withthe company w.1.the cited vehicieare true Ane ge oxen & MAA awd eda ater ot Aor weet Rte Ferecor ee AT ore GeV} aIeL aT A ag aR 8 Ae YR AR ret ere wa A Sh ng ere Ter TT wave A Fre aT SETS ATL Place rr Signature of Insured “ifr Bee Date feria: Shriram General Insurance Company Ltd. Head Office: E-8, EPIP, RIICO Industrial Area, Jaipur 302022, Ph 0141-3928400, Fax 0141-2770693