Motor Claimform

The Oriental Insurance Company Limited (Incorporated in India, subsidiary of General Insurance Corporation of India) Regd. Office: Oriental House, P.B. No.7037, A-25/25, Asaf Ali Road, New Delhi- 110 002 MOTOR CL AIM FORM Div. Br. Office Address_____________________ Certificate/Policy No.________________ Tel. No. Period of Insurance___________ Claim No.___________________________ THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY Please answer All relevant questions fully 1. INSURED (a) Na me :___________________ ________________________ (b) Addres s for correspondence : (c) Teleph one : 2. THE INSURED VEHICLE Make & Year Engine No. Chassis No. Registration No. (a) Was the vehicle in proper working condition? (b) For what purpose was the vehicle being used at the time of accident? (c) Was trailer attached? (d) If a Motor Cycle/scooter 1. Was a side-car attached 2. Was a pillion rider carried II. ADDITIONAL INFORMATION(COMM ERCIAL VEHICLE) The following questions need be answered in commercial vehicles only: (a) Regi stered laden weight :______________ (b) Unla de n Weight :______________ (c) Weight of goods carried/Load Challan No. :___ (d) Na tur e of pe rmit :____________ (e) Natur e of goods carri ed :_____________ (f) Was the vehicle plying for hire :________ _____ _____ (g) If Lorry/Je ep/Tract or, was trailor attache d? :___ (h) Number of pass enger s carr ied :____________ (i) Number of Passenger permitt ed :___

Motor Claimform

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