(To be filled in by the Insured Policy Holder or Insured’s Representatve duly authorized by Power and Atorney. Issuance of this claim form is not to be taken as an admission of liability.)

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Policy No.
 
Client No.
 
Details of the Insured Person and Vehicle
 
Insured Name
Address of Correspondence
City.
 
Pincode
Telephone No.
  Mobile  
Email
PAN No.
 
Vehicle No.
Engine No.
 
Chassis No.
 
Details of the Driver at the time of Accident
 
Name
Address
City.
 
Pincode
Telephone No.
  Email  
DOB
Driver is: Owner   Paid Driver   Relative/Friend.
Was he under infuence of liquor/drugs: Yes   No
Driving License No:
Issuing Authority
 
Driving License Expiry Date
Type of Vehicles authorized
to drive (tick one):
LMV    Transport    Motorcycle   
 
Details of the Accident and Damage to the Insured Vehicle
 
Date
  Time  
Place
Cause of Damage:
Accident Riot, Strike, Malicious Act Theft and Burglary
Flood, Storm, Tempest Fire, Explosion, Self-ignition Earthquake
Terrorism In transit  
No. of Occupants
 
Estimated Cost of Repairs
Give a short description of the accident:
 
Third Party Injury/ Death or Third Party Property Damage
(To be filled in only where a third party injury/death or third party property damage has taken place)
Name
Occupation
 
Is third party your employee Yes   No
Address
City.
 
Pincode
Full Details of Personal Injury
Name and Address of Hospital/Doctor attending to the injured person
City.
 
Pincode
Full details of Property damage
  Has a claim notice been given to you Yes   No
 
Injury to Driver / Occupant
(To be filled in only when the driver or the occupant is injured)
Was driver or any occupant injured   Yes   No  
If yes give details
 
Declaration by the Insured
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 if I/We have made of in any further declaration the Company may require respect of the said accident, shall make any false or faudulent 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.
I/We hereby declare that, notwithstanding anything to the contrary contained anywhere above, no credit of the service tax, education cess and secondary and higher education cess mentioned on this invoice will be availed by me/us or under, my/our instruction. The eligibility to avail such a credit vests in HDFC ERGO General Insurance Company Ltd. and I/we do not have any intention to avail such credits.
Place
Date
 
Instructions – Complete all items in the form and attach the following:
Accident Claims
  • Copy of the Registration Book
  • Copy of the driving license of the person driving at the time of accident
  • FIR, if accident reported to the police
  • Estimate of repairs
  • KYC, AML documents
  • Copy of the Fitness certificate of the vehicle (Commercial Vehicle)
  • Copy of the Road permit of the vehicle (Commercial Vehicle)
  • Registered load carrying capacity of the vehicles Copy of Lorry receipt (Commercial Vehicle)
  • For Accident Claims, the completed and signed claim from along with annexures should be given to the company’s representative at the time of vehicle survey at the garage.
  • For other claim send the form along with the annexures to our claim department: HDFC ERGO General Insurance Company Limited, 6th Floor, Leela Business Park, Andheri kurla Road, Andheri (East), Mumbai – 400 059.
  • Retain a copy of the documents sent for your records. If you have any claim related queries, please email us at: care@hdfcergo.com or call Customer Service no : 022 - 6234 6234 / 0120 - 6234 6234.
 

HDFC ERGO General Insurance Company Limited

Satisfaction Voucher
(To be obtained from the insured, where payment is being made directly to the repairer.)
 
Motor Claim No.
 
Motor Vehicle No.
I/We hereby acknowledge having received from
(Name of repairer/garage) my/our Motor Car/Vehicle/Motorcycle No. which has been
repaired to my/our satisfaction, and I/We admit that the payment of Rs. on account of such repairs by HDFC ERGO General
Insurance Company Limited is in full discharge of my/our claim upon the said company under policy no. in respect of the damage
caused to the said Motor Car/ Vehicle/Motorcycle in an accident that occurred on
 
Place:
 
Date:
Address:
 
 
Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Email: care@hdfcergo.com | Fax: 91 22 6638 3699 | www.hdfcergo.com
 

HDFC ERGO General Insurance Company Limited

Motor Loss Voucher
(To be obtained from the insured or the Repairer to whom payment is made)
 
Motor Claim No.
 
Policy No.
Do you want us to deposit the claim payable amount directly to your bank a/c   Yes   No  
IFSC Code
If Yes. Bank Name:
 
A/C Number:
Insured Name as per Bank Account:
 
Received from HDFC ERGO General Insurance Company Limited the sum of Rupees (In Words)
in full and final settlement of our bills and cash memos for accident repairs to and/or theft of Attachments
In Support of Bank Details (Please tick the type of proof submitted):   Cancelled Cheque   Bank Passbook Copy
 
E-mail Address:
Place:
 
Date:
 
 
Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Email: care@hdfcergo.com | Fax: 91 22 6638 3699 | www.hdfcergo.com
 

HDFC ERGO General Insurance Company Limited

 
Motor Loss Voucher
(To be obtained from the insured or the Repairer to whom payment is made)
 
Received this day of 20 from HDFC ERGO General Insurance Company
Limited the sum of Rupees (in words)
which I/we agree to accept in full satisfaction and discharge of all claims present or future under
Policy No. in respect of Vehicle No.
which occurred on Rs.(in figures)
 
Please affix
Revenue stamp
if the amount
exceeds Rs.500/-
 
 
(No Objection Note where the Financier wants the claim to be paid directly to the vehicle Owner)
I/We hereby authorise the Insurance Company that the amount stated above may be paid to the hirer.
 
 
Address of Claimant
 
 
 
Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Email: care@hdfcergo.com | Fax: 91 22 6638 3699 | www.hdfcergo.com