Claim Registration

Please enter following details for claim registration (Fields marked with * are mandatory)

Policy details

Policy/CN/ECN/BQA Number*

Registration Number

Model & Variant

Customer details

Customer Name

Email Id

Contact Number*

Accident Details

Third Party Property/Bodily injury*

Nature of Loss*

Location of Accident*

Description of Accident*

Was Vehicle Parked at the time of loss?*

Driver License Number*

Accident Date & Time*

HH*

MM*

Damaged Parts*

Driver Name*

Driver's Relationship with Insured*

Workshop/Garage details

Workshop Search By

Name
Workshop Code

Workshop Alternate Number

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 I/we agree that if 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 Company may forfeit the entire claim, and the Policy shall be null and void, and all rights to recover there under in respect of past or future loss/accidents shall be forfeited.