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Nibhaye Vaade
Claim Form for Motor Vehicle
()O BE FILLEDAND SIGNEDBY OWNER OFVEHICLE)
answer quesuons fully)
(Issuance Ofthis fo罒 is notto be taken as an admissionOfliability•Please

· 2· 666
For Claim registration, please call on Toll Free Number 1800
ABOUTINSURED:POLICY/COVER20秅 20.
INFORMATION CLAIMNO.

Name:

Res.Tel.No.
(Mobile n EmaillD is essentialforthe e 0 keep the customer informed about claim process)
su「

E Mail

AadharCard 0.

yea inco
Average 囗 lac 口 31actoSlac 口
囗Slact0101ac 加la 02 ac口 > 20h0
08 on 口 Semce 囗Marketing 囗 NonMarketing
口 Business 口 0 e「
s

, ofmen
山sth Family 口 <2 囗4 •8 口> 8

Howa nyof ema 0318 口 <2 O 27 0 4•8

of en,面 the vehicle

Howmany
面youhave
Howmanyvehicle 口2 囗> 2
囗 580-1c08 囗1 00•20000
囗 > 20000
Averagekmsrunnyear
囗 2 30「
more
、udatmedinlast2years囗
Howmanytmes none

口 Personal 口 Business 心 •ncity) Business(Outslde

city)

A心 De c 口 None 囗 GearLock 口 Tracking

Deuce

02 ABOUTINSUREDVEHICLE
FOR AT丨

20.
Registration
OfR , on
C is
Commercial Two Wheeler
C ofV由

0 LS ABOUTTHEORIVER m· Ofaccid

囗
囗
CorrespondenceAddress•

Relative/ friend Ⅱpaidd how longhas he been yourem 0 ?

囗
囗
MO Cycle Scooterw心吅~G「
9k5“ pe 囗 C]LCV 囗 囗

0 5d0 阝em if any

suspension
畿S をA、、い
00 ロロ

・・・・・・ ・・ ・ ・ ・・・ ・・ ・、
置:■ 第:・町■ 第 第■ ・
一■ ■ ・ 第、
■ ■ 第■ ■ ■ ■ ■ ■ ■ ・ ■ 第 可ー■ 第

ロロロロロエ ロロロüClüü ロロロエ ロ

ロロロロロロロロロロロロロロロ ロロロエ ロロ
ロロ

ロロロロロロロロロロロロ

DOCUMENTS REQUIRED

ロー物・一 、
口をこ0 物 ー ー
、 ・ 、
0ゞ 一 、
ロRこ ロ感 0を
ロ物 一0 “
- に ロ式-
ロ糖0 ・ ロ0 人お・ 0物
,. ー は 物 ロⅥ計ー
ロ引0物物、 口をこ0・、
“ き、'ー
ロー .お
ー ト
 Page30f4

, y affirm
and that.
、T ternen
| " m ongivet c e:,
b. T d a 0| p on Ⅵ
by , u$咖 $山而m tru cot
"ch ecla,•ni 'g, a
n e opertv, pectofwt eproved P e 0$ * |
policy.F h , " clammadehereunder , n ,1 ,〔 $made |0 any
and“〔 $providedtfisclosed
in $darn 皿
0 cecompany
theclam hasbeen : d not sc .
, .
NOmaterialinformation.
vålich is | 0 e processing
of 2claim.whichin Ⅳ ~be g
ad" ny , ,,
fraudulent , , $ pr”$
on 」,
conce any |0 c
mannerfaded
void d V e no u |oaⅣ , | 0「ov e齫d , , pec!Of V d" . p | orfute-
at d, d :0 , tut
, a e, ", con 此 , ,n dthe
Th e 0 $c m m/ 0 “, 叩 run , ddoa doe
$
Company thenghtto r
process, ec【 th /add infor" , r p【e 〔m.
Me Ⅱnottake credit e Ⅵc " pa心 C| Lombard
Input Gen ,, Ltd. men $" ~」1 , , e〔m.

Direct Fund Transfer/EFT Mandate FO

or'Otm. ,, a面'i。 by c罒p
S mi docum 0「
ba any0th orm , doe
$丨 ,
A) Would you like to opt fo「Electronic Fund Transfer as mode Ofpayment ? A) Yes

B)Ifyes, kindly provide the below mentioned details :

Type OfAccount:

Branch Name :

Mandatory
cheque signedby
1) Please attach an Original Blank cance"ed
Mandatory
Please attach a PAN card copy OfPavee

d 0 for payments ro h
Terms and C
, Ⅱ 00", ,· d“ final, Ltd•
G- " 0 "“,“00Company
Lombard 、 ,0 0” 0
Form
Mandate
I. Thedetails ~ edby 0c 00, , , in 0
cross verification any the details providedtherein•
"00
be · "0 , ,“p,, ec",、"0「
TheRTGS/NEFTfaciGtyshall
, 巧day,
c 0, b d G~ 00
0 ,, ,
“, “00 co, pa
eM, 0、Fo” Cㄦ0, b" dG“ 0 “,。
Ltd-to“、 0 theRIGS/ NEFT 0 Ⅳ.
may 「
00: requiredbyperiod“
CompanyLtd• 、
"
. 0may 0riskof in 0A000” c、 0, 、 dayof " 、of , 0" 面0、
3. TheC" 、,· 「 · de, 0 RTGS/NEFTf00
、「
LombardG 0 |"s", 0" 00 Co" 0「
y
b 0" d thecon
InsuranceCompany any f, 0t0「
Ltd•and心 d ke
0「 Lombard In“0 " 00
" “ · Ge「
dernur•心Lombard " 』|"、0 0company
4. TheC", 、、 09,- , 、 砈""
Ltd•may :
, , "00company 0, , ,0 、indirectlyanstngfrom in 0 "· 0 , , 0, 0" , things
fees)Much C 由 d G~
, C" 0, ,
t in 0
ver theafor” drea
of under 0 RTGS/NE f“刂
5. 心C " dG- " " ,0 0 CO'吅0 Ltd• ay “b•0 |,00 oyag- to0 Ⅳ、
、ICICILombardonW
"d ·d 0 ~ Ofsuch、 0 cㄦ0, " d, 仆0、 00of “cht· , , 、 0" should
The 、 ,、•0· Cㄦ"

了
, P a
, , ,·
Ⅵ, Mumbai · 40g25

A,, , , 、, ",, “" by 0 c" 0, 、, acknowledged“ , 0“… , " by · 0 "“,0, 0

Gen

atinq , , p| $uchcor "cat , Cu on r

 Page 4 of 4

7. The that transaction(s) through RIGS/ NEFT faciEty may attract inward RTGS/ NEFT charges, which if levied by the Customers bank. shall be
borne by the Custome

S. ICICI Loa±ard has the absoute discretion to amend or suppkment any Terms and Conditions stated herein at any time and will endeavor to give prior notice of Ten
days changes whereve feasile for the terms and conditions to be appbcable. By using the new services. or at the completion of such period. whichever is
eufet. the Customer shal be deemed to have accepted the changed terms and conditions.

9. of docurnents or bank de-tansor any other informationdoes not in any way. shape or form, imply or express or suggest admission of liability by the

10. Notices these terns and corditions may be given in writing by deEvering them by hand or e-rnad or on ICICI Lombard General Insurance Company Ltd. website
by selding them by post to the last address of the Customer.

These terms ard conditions wd be govemed by the laws Of India and any legal action or proceedings arising out of these Terms and Conditions shall be initiated in the
cmgts tricnals at Mumbai ln&a.
12- J/W€furtherundertaketorefundanyexcessamountw•hetherdemandedbylClCl Lombard General Insurance Company Ltd. or not. which has been credited in
excess to my accwnt at any 7 days of such receipt of such communicationfrom ICICI Lombard of such excess credit or such
due to anv reason w•vttun
•nfcrrnatim of excess credit com•ng to the knowledge of the Customer through any other source.

13. VV%aveethatmy/ourciaimpayrnentwiUbecreditedfrornthedatelClClLombardGenerallnsuranceCompanyLtd. getsconfirrnationfromitsbankers.Thisfacility

contiue uriess it is revoked by any party and any issuance of relevant credit instruction from ICICI Lombard General Insurance Company Ltd. to its bankers will
be vaEd til such Instruction is complete irrespective of the fact that the notice period has expired provided such a credit request has been made by ICICI Lombard
General Insurance Cornpany Ltd. before the expiry of the notice period of the Customer.

(Bease attach a blank canceJed cheque or photocopy of a cheque for verification of the particulars provided in this regard)

Signature of the Account Holder (Insured)

For any future claim or insurance related query please call on Toll Free Number 1800-2-666

"ICICICLombard
Nibhaye Vaade
Aurus: Lanbud GM" Insumce CunpanyL"rited InterfaceBuiung No.11.401/4024th Neo RoadMalad MIAai - 4Ü64.
W •s: Wed, 'CICI Hwse 414.Vee Near Sevi Prihadevt. Mumba 025.
Visit •t Now Org Numbe for al Insurance needs 1800 2666 (Toa Froe also •ccessile tram
is matterOf BOA REG. 115.