{"id":1020,"title":"MOTOR CLAIM FORM","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/motor_claimform_1_f2a869fd81.pdf","sha256":"ecd27a79b1e01187e2fdd3d27aeb77801dcb86774991e4656633d5beed496b35","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim motor insurance benefits after an accident or theft involving the insured vehicle.","notes":["The issue of this form is not an admission of liability.","Please answer all relevant questions fully."],"title":"MOTOR CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Div. Br. Office Address","options":[],"required":null,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Certificate/Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your telephone number","type":"phone","label":"Tel. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Claim number if already assigned","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Correspondence address of the insured","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Telephone number of the insured","type":"phone","label":"Telephone","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Insured Vehicle Details","fields":[{"help":"Vehicle make and manufacturing year","type":"text","label":"Make & Year","options":[],"required":null,"pdf_field":""},{"help":"Engine number of the vehicle","type":"text","label":"Engine No.","options":[],"required":null,"pdf_field":""},{"help":"Chassis number of the vehicle","type":"text","label":"Chassis No.","options":[],"required":null,"pdf_field":""},{"help":"Vehicle registration number","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Was the vehicle in proper working condition?","options":[],"required":null,"pdf_field":""},{"help":"Describe the vehicle's use at accident time","type":"text","label":"For what purpose was the vehicle being used at the time of accident?","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Was trailer attached?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information (Commercial Vehicle)","fields":[{"help":"Enter the registered laden weight","type":"text","label":"Registered laden weight","options":[],"required":null,"pdf_field":""},{"help":"Enter the unladen weight","type":"text","label":"Unladen Weight","options":[],"required":null,"pdf_field":""},{"help":"Enter weight of goods or load challan number","type":"text","label":"Weight of goods carried/Load Challan No.","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature of permit","type":"text","label":"Nature of permit","options":[],"required":null,"pdf_field":""},{"help":"Describe the goods carried","type":"text","label":"Nature of goods carried","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Was the vehicle plying for hire","options":[],"required":null,"pdf_field":""},{"help":"Enter number of passengers carried","type":"number","label":"Number of passengers carried","options":[],"required":null,"pdf_field":""},{"help":"Enter number of passengers permitted","type":"number","label":"Number of Passenger permitted","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Driver at the Time of Accident","fields":[{"help":"Driver's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Driver's age","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Driver's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Duration of employment","type":"text","label":"If paid driver, how long has he been in your employment","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Was he under the influence of intoxication Liquor or drugs?","options":[],"required":null,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving Licence Number","options":[],"required":null,"pdf_field":""},{"help":"Authority that issued the license","type":"text","label":"Issuing Authority","options":[],"required":null,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Date of Expiry","options":[],"required":null,"pdf_field":""},{"help":"Specify if license is temporary or permanent","type":"text","label":"Was the licence temporary/permanent","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Details of endorsement/suspension, if any","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no and details if yes","type":"text","label":"Has he been involved in any accident before?","options":[],"required":null,"pdf_field":""},{"help":"Explain if charged","type":"text","label":"Has he been charged by the policy? If so, Why?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Provide details of other insurance policies if any","type":"text","label":"Details of other insurance Policies indemnifying you in respect of this accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Accident","fields":[{"help":"Date and time of the accident","type":"text","label":"Date and Time","options":[],"required":null,"pdf_field":""},{"help":"Location of the accident","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Approximate speed of vehicle","type":"text","label":"Speed of vehicle at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe what happened","type":"text","label":"Give a short description of the accident","options":[],"required":null,"pdf_field":""},{"help":"Third party details if responsible","type":"text","label":"If any third party was responsible for this accident give the name and address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Damage to Insured Vehicle","fields":[{"help":"Describe the damage to your vehicle","type":"text","label":"Full details of damage","options":[],"required":null,"pdf_field":""},{"help":"Estimated repair cost","type":"amount","label":"Estimated cost of repairs","options":[],"required":null,"pdf_field":""},{"help":"Provide time and place for inspection","type":"text","label":"When and where can the damaged vehicle be inspected","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Third Party Injury/Property Damage","fields":[{"help":"Name of injured or property owner","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of injured or property owner","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries sustained","type":"text","label":"Full Details of personal injury sustained","options":[],"required":null,"pdf_field":""},{"help":"Medical provider details","type":"text","label":"Name and address of any person/hospital giving medical attention to injured person","options":[],"required":null,"pdf_field":""},{"help":"Describe property damage","type":"text","label":"Full details of property damaged","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Has notice of any claim been given to you?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Injury to Driver/Occupant","fields":[{"help":"Answer yes or no","type":"text","label":"Was driver/any occupant injured?","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries","type":"text","label":"If yes, give full details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Witness","fields":[{"help":"List witnesses with contact details","type":"text","label":"Give names and addresses of passengers/other Witness, if any","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Did a Police Constable take particulars of The accident?","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no and reason if no","type":"text","label":"Was accident reported to Police? If not, Why?","options":[],"required":null,"pdf_field":""},{"help":"Name of police station","type":"text","label":"If yes, to which Police Station?","options":[],"required":null,"pdf_field":""},{"help":"Date and diary number of police report","type":"text","label":"Date and Diary No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Theft","fields":[{"help":"Date and time of theft","type":"text","label":"Date and Time","options":[],"required":null,"pdf_field":""},{"help":"Location of theft","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Describe stolen items","type":"text","label":"What was stolen?","options":[],"required":null,"pdf_field":""},{"help":"Estimated replacement cost","type":"amount","label":"Estimated cost of replacement?","options":[],"required":null,"pdf_field":""},{"help":"Name of person who reported theft","type":"text","label":"By whom discovered and reported?","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"text","label":"Has theft been reported to Police?","options":[],"required":null,"pdf_field":""},{"help":"Date of police report","type":"text","label":"When?","options":[],"required":null,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Which Policy Station?","options":[],"required":null,"pdf_field":""},{"help":"Crime report diary number","type":"text","label":"C.R. diary Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The insured warrants the truth of the statements made in this form to the best of their knowledge and belief.","If any false or fraudulent statement or concealment is made, the policy shall be void and rights to claim forfeited."],"dropped_labels":6},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/oriental-insurance/1020-motor-claim-form"}