Bajaj Allianz Motor Insurance Claim (Page 2 of 3) in pdf

Bajaj Allianz Motor Insurance Claim Page 2

5.Statement of how the Accident / Theft occured :

6. Give a rough sketch describing the road map & position of the vehicle at the time of accident.

Driver Details

Name :

Relation with Insured :

Address :

Contact Number :

(If different from the one mentioned above)

Date of Birth as shown on the License

D D

M M

Y Y

Gender : Male / Female

Driving License No :

License Effective From :

Issuing RTO :

License Expiry Date :

Class : MCycle / LMV / HGV / Transport / Non-Transport

Type : Permanent / Learners

Occupant / Passenger / Third Party Injury Details

Sr. No.

Name

Address

Phone No.

In What

Capacity

Nature of Injury

Third Party Property Damage (include other vehicle involved)

Declaration

I/We the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect and agree that if I have made any false or

fraudulent statement of there be any suppression or concealment, the policy shall be cancelled and the claim shall be forfeited.

I/We have received a list of documents with this claim Form and have understood all the requirement to be fulfilled for administration of this claim and the Company shall not be held

responsible for any delay in settlement of claim due to non-fulfilment of requirements including the documents as mentioned above.

I/We agree to provide additional information to the Company, if required.

Name :

Signature of insured :

Date :

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