Motor Claim Form (OD)
Please complete all information required as under:
Claim No.:____________________
Policy No.:____________________
Policy period From_____________ to ______________
Nature of Coverage:_______________________
To be used in reporting of all accidents & / or losses involving automobiles. In case of serious accidents, fatalities &/or serious injuries
please contact our nearest offices immediately, as per below given address, and do not delay it because of lack of information.
NAME OF INSURED
Name:_____________________
Age________
Address:___________________________________________________
OPERATOR
DRIVER
Name:________________________ Age______________
Expiry Date___________________ License No._____________
Address:____________________________________
Plate No.________________ Chassis No._________________
INSURED
VEHICLE
Make_______________ Model_________________
Accident Date_____________
Time______________
Location_________________
INJURED
PERSONS
Name________________________ Age______________
Injury__________________________________________
Name of Hospital_______________________________________
Nature of Injury_________________________________________
Estimate of Claim________________________________________
________________________________________
OTHERS
PROPERT
DAMAGE
Name of Owner____________________________________________
Address___________________________________________________
Name of Operator/Driver_____________________________________
License No.____________________________
Give description Company, if Insured _________________________________
Estimate of Cost of Repairs or Replacement ____________________________
DAMAGE TO INSURED
VEHICLE
Description and extent of damage
(A) _________________________________________________
(B) _________________________________________________
Estimate of cost Repairs or Replacement ___________________
POLICE REPORT
Name of Officer_______________________________________
Address of Police station ________________________________
No. of Police Report ___________________________________
Please provide details of the accident
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
I/We hereby declare that the information provided herein above by me/us is true and correct to the best of my knowledge and belief,
and I have not misstated and/or concealed any material fact relating to the above accident. I/we further declare that I/we have no
other Insurance Policy in force to compensate me/us for this claim, otherwise all my rights under the claim shall be forfeited.
Date____________________
Signature of authorized person___________________________
Stamp.
Please submit the following documents:
Police or Najm Report.
Repair permission.
Copy of valid driver’s license.
Copy of registration book.
Repair estimate duly approved by the Insurers.
Original repair invoices after repair of the vehicle.
Medical report in cases of bodily injury.
Medical invoices supported by Police report stating expenses.
Death certificate in case of death claim.
Legal heir certificate for PAB claim.
Court verdict for 3rd party death claim.
Note: The company may, after review of the document, request for more information &/or document to consider the claim.