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    Claim Form

    Uploaded by

    aakash chauhan
    This document is a motor claim form from The New India Assurance Co Ltd in Oman. It collects information about a motor vehicle accident to process an insurance claim. It requests details about the insured, vehicle, driver, accident, damages, and injuries. The insured must sign agreeing the statement is true and acknowledging penalties for fraudulent claims. The form collects essential facts to evaluate the claim in 3 sentences or less.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Claim Form

    Uploaded by

    aakash chauhan
    148 views3 pages
    This document is a motor claim form from The New India Assurance Co Ltd in Oman. It collects information about a motor vehicle accident to process an insurance claim. It requests details about the insured, vehicle, driver, accident, damages, and injuries. The insured must sign agreeing the statement is true and acknowledging penalties for fraudulent claims. The form collects essential facts to evaluate the claim in 3 sentences or less.

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    This document is a motor claim form from The New India Assurance Co Ltd in Oman. It collects information about a motor vehicle accident to process an insurance claim. It requests details about the insured, vehicle, driver, accident, damages, and injuries. The insured must sign agreeing the statement is true and acknowledging penalties for fraudulent claims. The form collects essential facts to evaluate the claim in 3 sentences or less.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    148 views3 pages

    Claim Form

    Uploaded by

    aakash chauhan
    This document is a motor claim form from The New India Assurance Co Ltd in Oman. It collects information about a motor vehicle accident to process an insurance claim. It requests details about the insured, vehicle, driver, accident, damages, and injuries. The insured must sign agreeing the statement is true and acknowledging penalties for fraudulent claims. The form collects essential facts to evaluate the claim in 3 sentences or less.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    THE NEW INDIA ASSURANCE CO LTD.

    P.O.BOX 2907, PC 112, RUWI


    SULTANATE OF OMAN

    MOTOR CLAIM FORM


    (THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY)

    Policy No:.………………………………......................... …. Period of Insurance:…./…./…….to….../…. /……

    Insured Name: ……………………………………………………………………………………………..

    Tel Nos:………………………….. Res:…………………………. G.S.M :……………………………….

    Regn:No:…………………………………Vehicle Make:………………………….Model:………………..

    Engine No.:………………………………… Chassis No :………………………………………………….

    Was the vehicle in proper working condition:……………………………………………………………….

    For what purpose was the vehicle


    being used at the time of accident:……………………………………………………………………………

    Full details of damages:………………………………………………………………………………………

    Estimated cost of repairs:……………………………………………………………………………………..

    When and where the damaged vehicle can beinspected:……………………………………………………..

    DRIVER DETAILS

    Name of driver at the time of accident:………………………………………………………………………

    Date of birth:……./………../……………… Age: ……………………..years

    Driving License Number:………………………………… Date of Issue :………/…………./……………..

    Date of Expiry………:/………/………….. Issuing Authority:……………………………………………..

    Is the driver 1- Owner 2 - Paid Driver 3-Owner’s relative of friend

    If paid driver, how long has been in your employment?................................................................................

    Was he under the influence of intoxication liquor or drugs?..........................................................................


    Has he been involved in any accident before?................................................................................................

    Type of vehicles authorized to drive:………………………………………………………………………...


    ACCIDENT DETAILS

    Date:……………………………….. Time:………………………….Place:……………………………….

    Speed of your vehicle at the time of accident?...............................................................................................

    Give a short description of the accident:........................................................................................................

    ……………………………………………………………………………………………………………….

    ……………………………………………………………………………………………………………….

    ……………………………………………………………………………………………………………….

    THIRD PARTY PROPERTY DAMAGE

    TP Vehicle Regn. No:………………………………. Make:……………………… Model:……………….

    Full details of property damaged:…………………………………………………………………………….

    THIRD PARTY PERSONAL INJURY

    Was driver/ any occupant injured:……………………………………………………………………………

    Names of Injured Persons: Type of Injury Contact Numbers

    1……………………………………… …………………………… ………………………………...

    2……………………………………… …………………………… ………………………………...

    3……………………………………… …………………………… ………………………………...

    4……………………………………… …………………………… ………………………………...

    5……………………………………… …………………………… ………………………………...

    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 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 there under in respect of past
    or future accidents shall be forfeited.
    Date: ……/………/………………… Signature of the Insured

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