{"id":1221,"title":"Motor Insurance Claim Form and discharge voucher","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/Motor-Insurance-Claim-Form-and-discharge-voucher.PDF","sha256":"60e8a1042f8e16329d58d39f9ec29b984ab391e9898ed2df5c468f61d229b4d0","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons to claim motor insurance benefits and to provide discharge confirmation after claim settlement.","notes":["Please fill in all columns of the claim form.","Attach separate sheet if the space is not sufficient.","The form is bilingual in English and Hindi.","The discharge voucher requires a revenue stamp.","Signature of insured is mandatory on claim form and discharge voucher."],"title":"Motor Insurance Claim Form and discharge voucher","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details / बीमित विवरण","fields":[{"help":"","type":"text","label":"Claim Number: दावा नम्बर","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number: पॉलिसी नम्बर","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured: बीमित","options":[],"required":null,"pdf_field":""},{"help":"Enter start date of insurance period","type":"date","label":"Period of Insurance: (From) बीमे की समय अवधि (कब से)","options":[],"required":null,"pdf_field":""},{"help":"Enter end date of insurance period","type":"date","label":"(To) (कब तक)","options":[],"required":null,"pdf_field":""},{"help":"Include area code if applicable","type":"phone","label":"Telephone Number (Landline): टेलीफोन नम्बर","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"(Mobile) मोबाईल","options":[],"required":null,"pdf_field":""},{"help":"Full postal address for communication","type":"text","label":"Address (where all correspondence be done regarding this claim): पता","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Vehicle Detail / वाहन का विवरण","fields":[{"help":"Vehicle registration number","type":"text","label":"Regd. No पंजीकृत संख्या","options":[],"required":null,"pdf_field":""},{"help":"Date vehicle was registered","type":"date","label":"Date of Registration पंजीकरण दिनांक","options":[],"required":null,"pdf_field":""},{"help":"Name of authority where vehicle registered","type":"text","label":"Registration Authority पंजीकरण प्राधिकरण","options":[],"required":null,"pdf_field":""},{"help":"Vehicle make and model","type":"text","label":"Make & Model","options":[],"required":null,"pdf_field":""},{"help":"Fuel type (e.g. petrol, diesel)","type":"text","label":"Type of Fuel ईधन का प्रकार","options":[],"required":null,"pdf_field":""},{"help":"Vehicle color","type":"text","label":"Color of Vehicle वाहन का रंग","options":[],"required":null,"pdf_field":""},{"help":"Name of registered owner","type":"text","label":"Registered Owner पंजीकृत मालिक","options":[],"required":null,"pdf_field":""},{"help":"Details if ownership was transferred","type":"text","label":"Transfer of Ownership (if any) मालिकाना हक का स्थानान्तरण","options":[],"required":null,"pdf_field":""},{"help":"Engine number of vehicle","type":"text","label":"Engine No इंजन नं","options":[],"required":null,"pdf_field":""},{"help":"Chassis number of vehicle","type":"text","label":"Chassis No चेसिस नं","options":[],"required":null,"pdf_field":""},{"help":"Body type of vehicle","type":"text","label":"Type of Body बॉडी का प्रकार","options":[],"required":null,"pdf_field":""},{"help":"Vehicle class/category","type":"text","label":"Class of Vehicle वाहन का प्रकार","options":[],"required":null,"pdf_field":""},{"help":"Number of seats in vehicle","type":"number","label":"Seating Capacity बैठने की क्षमता","options":[],"required":null,"pdf_field":""},{"help":"Name and policy number of previous insurer","type":"text","label":"Previous Insurer Name & Policy Number पूर्व बीमा कंपनी का नाम व पॉलिसी नं","options":[],"required":null,"pdf_field":""},{"help":"Expiry date of previous insurance policy","type":"date","label":"Expiry Date of Previous Insurer Policy पूर्व पॉलिसी की समाप्ति तिथि","options":[],"required":null,"pdf_field":""},{"help":"Details of claims made under previous policy","type":"text","label":"Claim History in Previous Insurer's Policy पूर्व पॉलिसी पर दावों का विवरण","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Accident/Theft Details / दुर्घटना/चोरी का विवरण","fields":[{"help":"Date when accident or theft occurred","type":"date","label":"Date of Accident/Theft दुर्घटना/चोरी की दिनांक","options":[],"required":null,"pdf_field":""},{"help":"Time of accident or theft","type":"text","label":"Time समय","options":[],"required":null,"pdf_field":""},{"help":"Location of accident or theft","type":"text","label":"Place of Accident/Theft दुर्घटना/चोरी का स्थान","options":[],"required":null,"pdf_field":""},{"help":"Estimated amount of loss or damage","type":"amount","label":"Estimated Loss Amount अनुमानित नुकसान राशि","options":[],"required":null,"pdf_field":""},{"help":"Workshop details for repairs","type":"text","label":"Name and Address of the Workshop with Phone No कार्यशाला का नाम व पता एवं टेलीफोन नं.","options":[],"required":null,"pdf_field":""},{"help":"Reason vehicle was in use during incident","type":"text","label":"Purpose for which Vehicle was being used at the time of Accident/ Theft दुर्घटना/चोरी के समय वाहन का उपयोग किस प्रयोजन के लिए किया जा रहा था","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers in vehicle at time of incident","type":"number","label":"Number of Person Travelling at the Time of Accident/Theft दुर्घटना/चोरी के समय पर वाहन में कुल सवारियों की संख्या","options":[],"required":null,"pdf_field":""},{"help":"FIR number and police station name if filed","type":"text","label":"FIR No. (If reported to Police) & Name of Police Station एफआईआर नं (अगर थाने में रिपोर्ट की) एवं पुलिस थाने का नाम","options":[],"required":null,"pdf_field":""},{"help":"Description of how accident or theft happened","type":"text","label":"Circumstances & Cause of Accident/Theft दुर्घटना/चोरी की परिस्थितियाँ एवं कारण","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Commercial Vehicle Details / वाणिज्यिक वाहन का विवरण","fields":[{"help":"Fitness certificate number of vehicle","type":"text","label":"Fitness Certificate No फिटनेस प्रमाण पत्र नं","options":[],"required":null,"pdf_field":""},{"help":"Expiry date of fitness certificate","type":"date","label":"Expiry Date समाप्त की दिनांक","options":[],"required":null,"pdf_field":""},{"help":"Load carrying capacity for goods vehicle","type":"text","label":"Carrying Capacity (good vehicle) ले जाने की क्षमता (माल वाहन)","options":[],"required":null,"pdf_field":""},{"help":"Details of load challan if applicable","type":"text","label":"Details of Load Challan लोड चालान का विवरण","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers vehicle can carry","type":"number","label":"Passenger Carrying Capacity सवारी की क्षमता","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers at time of accident","type":"number","label":"No of Passengers at the time of accident दुर्घटना के समय कुल सवारियों की संख्या","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Third Party Claims Details / तृतीय पक्ष के दावे का विवरण","fields":[{"help":"Name of third party injured or deceased","type":"text","label":"Name / नाम","options":[],"required":null,"pdf_field":""},{"help":"Address of third party","type":"text","label":"Address / पता","options":[],"required":null,"pdf_field":""},{"help":"Nature of injury or death details","type":"text","label":"Detail of Injury / चोट का विवरण (Major/Minor/Death)","options":[],"required":null,"pdf_field":""},{"help":"Indicate if third party is your employee","type":"choice","label":"Your Employee / आपका कर्मचारी (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital name where treatment was provided","type":"text","label":"Name of the Hospital where treatment done हॉस्पिटल का नाम जहाँ उपचार किया गया","options":[],"required":null,"pdf_field":""},{"help":"Estimated value of third party property damage","type":"amount","label":"Estimated Third Party (If not your Own) Property Damaged (If Any) तृतीय पक्ष की अनुमानित क्षतिग्रस्त सम्पत्ति","options":[],"required":null,"pdf_field":""},{"help":"Registration number of other vehicle involved","type":"text","label":"Registration No. of other vehicle responsible for accident दुर्घटना के लिए जिम्मेदार अन्य वाहन का पंजीकरण नं","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Driver Details / चालक का विवरण","fields":[{"help":"Name of driver at time of accident","type":"text","label":"Driver Name चालक का नाम","options":[],"required":null,"pdf_field":""},{"help":"Driver's address and phone number","type":"text","label":"Address with Telephone Number पता एवं टेलीफोन नं","options":[],"required":null,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving License No चालक लाइसेंस संख्या","options":[],"required":null,"pdf_field":""},{"help":"License validity start date","type":"date","label":"Effective From कब से","options":[],"required":null,"pdf_field":""},{"help":"License validity end date","type":"date","label":"To कब तक","options":[],"required":null,"pdf_field":""},{"help":"Owner of the vehicle","type":"text","label":"Registered Owner पंजीकृत मालिक","options":[],"required":null,"pdf_field":""},{"help":"Type of driving license","type":"text","label":"Type of license लाइसेंस का प्रकार","options":[],"required":null,"pdf_field":""},{"help":"Select license type","type":"choice","label":"Learning /Permanent अस्थाई / स्थाई","options":["Learning","Permanent"],"required":null,"pdf_field":""},{"help":"Types of vehicles driver is authorized to drive","type":"text","label":"Authorized to drive the types of vehicles किस प्रकार के वाहन चलाने के लिए अधिकृत है।","options":[],"required":null,"pdf_field":""},{"help":"Details of any license endorsements or suspensions","type":"text","label":"Details of Endorsement / Suspension, if any पृष्ठांकन/निलंबन का ब्यौरा यदि कोई हो","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"NEFT Payment Detail / एनईएफटी भुगतान का विवरण","fields":[{"help":"Name of bank account holder","type":"text","label":"Bank Account Holder Name खातेदार का नाम","options":[],"required":null,"pdf_field":""},{"help":"Father or husband's name as per bank records","type":"text","label":"Father/Husband Name in Bank Account बैंक खाते में पिता/पति का नाम","options":[],"required":null,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name बैंक का नाम","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name शाखा का नाम","options":[],"required":null,"pdf_field":""},{"help":"Address of bank branch","type":"text","label":"Branch Address शाखा का पता","options":[],"required":null,"pdf_field":""},{"help":"City of bank branch","type":"text","label":"City शहर","options":[],"required":null,"pdf_field":""},{"help":"State of bank branch","type":"text","label":"State राज्य","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account Number खाता संख्या","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code आई.एफ.एस.सी संख्या","options":[],"required":null,"pdf_field":""},{"help":"Type of bank account (Savings/Current)","type":"text","label":"Account Type खाते का प्रकार","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Place where form is signed","type":"text","label":"Place स्थान:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date दिनांक:","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured बीमित के हस्ताक्षर","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Discharge Cum Satisfaction Voucher","fields":[{"help":"Claim number","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Amount received as full and final settlement","type":"amount","label":"Received from SHRIRAM GENERAL INSURANCE CO. LTD. the sum of Rs.","options":[],"required":null,"pdf_field":""},{"help":"Policy number related to claim","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Description of damaged or lost item","type":"text","label":"in respect of damage to / loss of","options":[],"required":null,"pdf_field":""},{"help":"Confirm satisfaction with settlement","type":"checkbox","label":"I am fully satisfied with Full & Final settlement with respect to my claim.","options":["Yes"],"required":true,"pdf_field":""},{"help":"Affix revenue stamp here","type":"attachment","label":"Revenue Stamp","options":[],"required":null,"pdf_field":""},{"help":"Signature confirming discharge","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Signature of surveyor verifying insured's signature","type":"signature","label":"Insured Signature Verified (Signature of Surveyor)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"motor insurance claims","attachments":["Separate sheet if space is insufficient","Revenue Stamp on discharge voucher"],"declarations":["The issue of this form is not an admission of liability.","I confirm that I had proposed for insurance of my cited vehicle which is evidenced by the Policy issued by Shriram General Insurance Company Ltd.","I confirm that all information furnished to the Company though the proposal and any other interactions with the company w.r.t. the cited vehicle are true.","I am fully satisfied with Full & Final settlement with respect to my claim."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"chd@shriramgi.com","label":"Help Desk Email ID for claim intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ase download the CLAIM INTIMATION SHEET, fill it and send it to our Help\n                            Desk via Email ID (chd@shriramgi.com)\nNote:\nPlease ensure that the following information is ready with you at the time of\n                            claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-300-30000","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 4:00 AM to Midnight 12:00","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"Option 1:\nIntimate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-3009","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 9:30 am to 5:30 pm","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our Help","fetched_at":"2026-10-20"}],"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/shriram-general-insurance/1221-motor-insurance-claim-form-and-discharge-voucher"}