‘CHOLAMANDALAM MS GENERAL INSURANCE CChennal - 600 003. Registered and Head Office: Dare House, 2nd Floor, No.2, N.C. Bose Road, ‘COMPANY LIMITED MOTOR INSURANCE CLAIM FORM {The feeuance of tis form does not Imply admision of ably) i Occupation Salored [] settempined|-] others miterne? LLL LL LLIL Lt i wobiene.9941 1 | 1 | 1 LL | Je") Passpor] ot (] -no F 7 een LL evo st LE LL LLL L ailiD| EmaliD | looor iat No: | Steet Name) 5 iy iE fbb area/vitage FeNo Baby: mwoandoate: ||| Fnac nterestif any (Please do not eismantle the vehicle tl iss subject toe dele survey) No of Peter teaveing nthe vehi: ‘elng fore ‘bay Toe Paty was noe a he Accent: Was the Acciderifbaf Reported to Pole: Yes/No Name ofthe Poe Staton: Dessioen of the Ace Tet Loss Detalls Datoof toss: |_| | ‘timeoftess:! | | “wor receottoss | | I LL | pLiti | states! | i For what purpose waste veil being used atthe tine of Acer Natare and Weight of the Goods Careor Goods Ceming Voices caupente Fate py Patongare- Cty He:Clam on Add on Covers under Chola Protect Sno. Name of heer ‘Modeler W/O Number ong Aon) cos | Sage Na ne ested ost ate ie ofl o Gage Driver Detals amo ofthe ever eee { Nomecrorhantag: | oe Liew! yor | ving cree Ha: || | oat ore: oo Daw wow | Nee & cate ofthe ung Author: L J.J pate of xy tov brawl vw | "ype oie Retort oO Moore UNH /3/HS VL Whether the esr oer Fi eRe ens spect Injury to Third Party/Occupants/Driver name haere are of ey Whether Third Pry/Occpent/Ovr Dall of hind Paty Daag: Other insurance Detals: is there any ater nse poy nding you resp of i acide ves Ro Nae of the Compares ‘tyes Poe Ne (7s herby dedare tht te above parila ae true and carat in each an every aspat |g to provide ay further oration /docamantsasstance thetinay be required for procsingmyjour clams. neat fay formation Tunshed by me/representatveis found correc, we ape to ace the ‘edlon of ermpany on ndmaBty of he cam, Paces Signatie of he insured with Sea) ‘we erway authori Cholamandalam MS General insurance Coto transfer the elim amount pyle under Clim No. tomybanksecountna, | enka rach, loatedat_—— ‘hy The IER Coe andthe Codes, exon Type: Place: Signature of he insured wit eat Document Encased (Fr Office Use aly) sr Form yeti Permit ReCooy Satria ‘roshet/iaed Olan Dicom Polley copy (Sebmisea] veer] rR fe Sabie He eos ttate [ined vice aries] Vea]Discharge Voucher Please return this receipt duly stamped and signed to enable the company to make payment acid asm of wards ul and il selement ofthe aim no, The ay has eon expe te am es simp Satur of re Rear with Seal -a4e----- -%--------#e -----— co we ‘CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED Registered and Head Office: Dare House, 2nd Floor, No2, N.C. Bose Road, Chennal - 600 001. } Chola@Ms List of Documents required for claim settlement {To be submites tothe nearby Chlamandaiam MS office / Surveyor / Repairer) ‘Cai for acide damages: 1 Proof of surance - Poy Coverot copy 2. cop of Registration ok, Tax Recep [Pls furs cin forveriatn) 3. Cony of Matr Dring Lane [wth erga ofthe person dng the wve athe mater ine 14, Pole Panchanam/FR {In cat of The Fert property damage [Death Boy nuyMsjor Loss Cais) 5. Estate for repair tom the grag where the vile tobe rene 6. Rept Ble and poymant recap ter the obs completed 7. Canceled cha eat for HEF transfer 18. ese sgn the attached acharge voucher sar conan ofthe ral him arcu. For assistance Please Call us at our Toll Free No: 1 800 200 55 44Satisfaction Voucher Please return this receipt duly stamped and signed to enable the company to make payment swehereby con tet VehNo__ been reps to mysntacion nde fully ducerge Colamandalm Gaara isurace Company Lem allibitis unde this cm We aa are to poy ry shee o la, any ect to the reper whee casas hasbeen wae.” tees vs ovrue some Whee Sigatire fe Cmart tna fi camany name) - a4 —------ e-- - - - — 4 — = —- ‘CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED Registered and Head Office: Dare House, 2nd Floor, No.2, N.S. Bose Read, ‘Chennai - 600 002, Y Chola@Ms List of Documents required for claim settlement (Fo be submited to the nearby Cholamandalem MS office / Surveyor / Repairer) ‘lim for aeidetal damages: tga Poly document ‘ovina Reistrtion Book/Catat and Tox Payment Rept Fravous insurance des Poy Ho, suring Ofle/Company peti of surance its of keys/ServesBoolet/Woreanty Crd Felice Panchanama/ FR and Final kvesigaton Report Acros coo of leteraderessedt RTO inmate and mang vik orn 28,29 nd 30 gn bythe insted ad Form 35 sled bythe Finances lata of Sregton ‘8, Consent toward agreed elm satlersent vale frm you and Finance 10.NOC ofthe Fiancerif enim st be seed in your veut 11. blak and undated Valsts 12.Cnealind geal for NEFT 13 ese sign the attache decree voucher for companstion of the alc amount. Additonal docbments in spec das shall inmatod separately. owe te ein ee the cave maybe undated sake For assistance Please Call us at our Toll Free No: 1 800 200 55 44