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CLAIM NUMBER
(For Office Use only)
POLICY NUMBER
INSURED ADDRESS
PINCODE Mobile No
STD Code Landline
E-Mail
REGISTRATION NO
CHASSIS NUMBER
VEHICLE DETAILS ENGINE NUMBER
MAKE MODEL
HYP/HPA IF ANY
DATE OF LOSS
TIME OF LOSS
DATE & PLACE OF LOSS
Vill/Town
PLACE OF ACCIDENT/THEFT
Mdl: Dist:
DRIVER ADDRESS
ACCIENT DETAILS
VNS BO MNCL 1
rÉÑlÉÉCOåûQû CÇÌQûrÉÉ ClzrÉÔUåUålxÉ MÇümÉlÉÏ ÍsÉÍqÉOåûQû
UNITED INDIA INSURANCE CO. LTD.
Regd. & Head Office : 24, Whites Road, Chennai. Visit us at www.uiic.co.in
Address of workshop
WORKSHOP DETAILS
Workshop contact Estimated loss
Workshop Mobile Workshop Phone
Workshop Fax Workshop E-mail
Third party
Yes No If Yes, provide additional information
involved
Third party
Death Injury Property damage
loss type
Driver injured
Third
THIRD party
Details of Loss Treatment Hospital
PARTY LOSS Name Age Address Phone vehicle Remarks
Third party type undergone details
DETAILS no (if
loss (Attach
applicable
separate sheet)
Account Number
INSURED
BANK BANK NAME BRANCH
DETAILS IFSC CODE
( 9 Digits)
DECLARATION BY 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 that 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.
Place:
Date :
Signature of Insured / Claimant.
VNS BO MNCL 2