{"id":13,"title":"STAND-ALONE OWN DAMAGE PRIVATE CAR POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/Claim_Form_Stand_Alone_Own_Damage_Private_Car_Policy_a5c1015eaa.pdf","sha256":"db35b0a8aa10c7d362280e369f0f74da4b73c79e67ec08da26eebbdfeac228f6","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim for own damage or theft under the Stand-Alone Own Damage Private Car Policy.","notes":["Fill the form in CAPITAL LETTERS and sign it.","Do not leave any column unanswered; mention 'N/A' if not applicable.","If information is not readily available, send the form without delay and provide other particulars later.","Attach an ORIGINAL BLANK CANCELLED CHEQUE signed by the Payee and a PAN CARD copy for EFT.","Submission of documents or bank details does not imply admission of liability by the company.","Use original documents for verification where specified.","The RTGS/NEFT facility will be effective within 15 days of receipt of mandate form.","The customer agrees to indemnify the company against claims arising from RTGS/NEFT transactions.","Termination of RTGS/NEFT facility requires 15 days prior written notice to the company.","Terms and conditions for payments through RTGS/NEFT are governed by Indian law and Mumbai courts."],"title":"STAND-ALONE OWN DAMAGE PRIVATE CAR POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. Details Of Insured / Claimant","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance: To","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Telephone STD code","type":"number","label":"STD code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Details Of Loss / Damage / Accident / Theft","fields":[{"help":"Date of accident or theft","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Specify time and select A.M or P.M","type":"text","label":"Time","options":["A.M","P.M."],"required":null,"pdf_field":""},{"help":"Location of accident or theft","type":"text","label":"Location","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Select the road type where accident occurred","type":"choice","label":"Road Type","options":["Express Way","Hill Road","National / State Highway","City / Town Road","District Road","Other"],"required":null,"pdf_field":""},{"help":"Speed in kmph","type":"number","label":"Speed at the time of acident","options":[],"required":null,"pdf_field":""},{"help":"Select applicable loss type","type":"choice","label":"Type of Loss","options":["Own Damage","Theft","Partial Theft (specify)","Third Party Death","Third Party Injury","Third Party Property Damage","Personal Accident"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Purpose for which the vehicle was being used at the time of accident / Theft","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Number of persons travelling","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Any other vehicle involved","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of person possessing keys","type":"text","label":"In case of theft, keys in the possession of? Name","options":[],"required":null,"pdf_field":""},{"help":"Phone number of key possessor","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of key possessor","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Name of contact person at accident location","type":"text","label":"Contact Details of person/s at the Location Name","options":[],"required":null,"pdf_field":""},{"help":"Relationship of contact person with insured","type":"text","label":"Relationship with Insured","options":[],"required":null,"pdf_field":""},{"help":"Phone number of contact person","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of contact person","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email of contact person","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Describe what caused the loss or accident","type":"text","label":"Describe cause of Loss / Damage / Accident","options":[],"required":null,"pdf_field":""},{"help":"Draw and describe accident spot and vehicle position","type":"text","label":"Please draw a sketch of spot of accident & describe position of vehicle at the time of accident, including nearby landmarks","options":[],"required":null,"pdf_field":""},{"help":"Indicate if FIR/DDR/GDR is filed","type":"yes-no","label":"FIR / DDR / GDR if any","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain reasons if FIR/DDR/GDR not filed","type":"text","label":"If not (reasons)","options":[],"required":null,"pdf_field":""},{"help":"Enter FIR/GDR/DDR number","type":"text","label":"Police FIR / GDR / DDR Details No.","options":[],"required":null,"pdf_field":""},{"help":"Date of FIR/GDR/DDR","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Police Station Name","options":[],"required":null,"pdf_field":""},{"help":"Date related to police station entry","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"City of police station","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of police station","type":"text","label":"State","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Garage Details","fields":[{"help":"Name of garage where vehicle is repaired","type":"text","label":"Garage Name","options":[],"required":null,"pdf_field":""},{"help":"Address of garage","type":"text","label":"Garage Address","options":[],"required":null,"pdf_field":""},{"help":"Contact person at garage","type":"text","label":"Garage Contact Person Name","options":[],"required":null,"pdf_field":""},{"help":"Phone number of garage","type":"phone","label":"Garage Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Email of garage","type":"email","label":"Garage Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. Vehicle Details","fields":[{"help":"Vehicle registration number","type":"text","label":"Reg. No.","options":[],"required":null,"pdf_field":""},{"help":"Vehicle make","type":"text","label":"Make","options":[],"required":null,"pdf_field":""},{"help":"Vehicle model","type":"text","label":"Model","options":[],"required":null,"pdf_field":""},{"help":"Chassis number","type":"text","label":"Chassis No.","options":[],"required":null,"pdf_field":""},{"help":"Engine number","type":"text","label":"Engine No.","options":[],"required":null,"pdf_field":""},{"help":"Odometer reading at time of accident","type":"number","label":"Odometer Reading","options":[],"required":null,"pdf_field":""},{"help":"Vehicle color","type":"text","label":"Colour","options":[],"required":null,"pdf_field":""},{"help":"Date vehicle was registered","type":"date","label":"Date of Registration","options":[],"required":null,"pdf_field":""},{"help":"RTO jurisdiction of vehicle registration","type":"text","label":"RTO Jurisdiction","options":[],"required":null,"pdf_field":""},{"help":"Select vehicle class","type":"choice","label":"Vehicle Class","options":["Two Wheeler","Private Car","Others (specify)"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. Driver Details","fields":[{"help":"Name of driver at time of accident","type":"text","label":"Name of Driver","options":[],"required":null,"pdf_field":""},{"help":"Driver's date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Relationship of driver with insured","type":"text","label":"Relationship with Insured","options":[],"required":null,"pdf_field":""},{"help":"Select gender of driver","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Select driver's education qualification","type":"choice","label":"Qualification","options":["Below 10th Std.","10th Pass","12th Pass","Graduation","PG"],"required":null,"pdf_field":""},{"help":"Telephone STD code","type":"number","label":"STD code","options":[],"required":null,"pdf_field":""},{"help":"Driver's phone number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Driver's mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Driver's email","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving License No.","options":[],"required":null,"pdf_field":""},{"help":"License issue date","type":"date","label":"Date of Issue","options":[],"required":null,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Date of Expiry","options":[],"required":null,"pdf_field":""},{"help":"RTO which issued license","type":"text","label":"Issuing RTO","options":[],"required":null,"pdf_field":""},{"help":"Select license type","type":"choice","label":"Type of License","options":["Permanent","Temporary"],"required":null,"pdf_field":""},{"help":"Select license class","type":"choice","label":"Class","options":["M-Cycle W/G","M-Cycle Wo/G","LMV","Transport","Non-Transport","HGV","Passenger"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. Third Party Death / Injury / Personal Accident Details","fields":[{"help":"Serial number for each person","type":"number","label":"SI No.","options":[],"required":null,"pdf_field":""},{"help":"Name of third party or injured person","type":"text","label":"Name of person","options":[],"required":null,"pdf_field":""},{"help":"Is the person a third party passenger?","type":"yes-no","label":"Whether TP passenger","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Address of the person","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of the person","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Specify death or injury details","type":"text","label":"Death / Type of Injury","options":[],"required":null,"pdf_field":""},{"help":"Hospital name if admitted","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Doctor attending the person","type":"text","label":"Name of Attending Doctor","options":[],"required":null,"pdf_field":""},{"help":"Provide details if any legal notice received","type":"text","label":"Details of any legal/Court Notice received","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of insured or claimant","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Print name of insured or claimant","type":"text","label":"Name of Insured / Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Select Yes or No","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Payee Name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee Account No.","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account","options":["Saving","Current","Other"],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the Bank","options":[],"required":null,"pdf_field":""},{"help":"IFSC code","type":"text","label":"IFSC Code of the Bank","options":[],"required":null,"pdf_field":""},{"help":"MICR code","type":"text","label":"MICR Code No. of the Bank","options":[],"required":null,"pdf_field":""},{"help":"PAN of payee","type":"text","label":"Permanent Account Number (PAN) of Payee","options":[],"required":null,"pdf_field":""},{"help":"Signature for EFT mandate","type":"signature","label":"Signature of the Account Holder (Insured)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Stand-Alone Own Damage Private Car Policy claims","attachments":["Original Policy document","Original Registration Book / Certificate and Tax Payment Receipt","All the set of keys / Service Booklet / Warranty Card / Original Purchase Invoice","Police Panchanama / FIR and Final Report / Non Traceable Report","Acknowledged copy of letter addressed to RTO intimating theft and informing “NON-USE”","Form 28, 29 and 30 signed by the insured and Form 35 signed by the Financier","Subrogation cum special Power of Attorney","Consent towards agreed claim settlement value from yourself and Financer","NOC from the Financer if claim is to be settled in your favour","Indemnity bond & discharge voucher","ID Proof (Passport, Driving license, Voter ID, PAN card, Aadhaar card)","Address proof (Passport, Driving license, Voter ID, Aadhaar card)","Proof of insurance - Policy / Cover Note copy","Copy of Registration Book, Tax Receipt (Please furnish original for verification)","Copy of Motor Driving License of the person driving the vehicle at the time of accident (Please furnish original for verification)","Police Panchanama / FIR","Estimate of repairs from the repairer where the vehicle is to be repaired","Repair Bills / Invoices and payment receipts after the job is completed","Discharge Voucher","ID Proof (Passport, Driving license, Voter ID, PAN card, Aadhaar card)","Address proof (Passport, Driving license, Voter ID, Aadhaar card)"],"declarations":["The insured warrants the truth of the statements and understands that false or fraudulent statements may forfeit the claim and policy.","The insured has attached the list of documents and understands the requirements for claim administration.","The insured agrees to provide additional information and authorizes the company to access relevant information for the claim."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102","label":"Claims postal address","level":null,"hours":null,"applies_to":"life","source_url":"https://acko-cms.ackoassets.com/2_Acko_Life_Group_Term_Protect_Micro_Insurance_Master_Policy_Document_ca9093f4de.pdf","quote":"at claims.life@acko.com or by sending the documents to the address mentioned below or any other office of the Company:\nClaims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102\n\nAny person claiming the Death Benefit under this Policy can download the claim request documents from Our website www.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-210-1992","label":"Claims phone number","level":null,"hours":"9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/claims/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nACKO Life Insurance Claims Process\nGroup Claims Process\nClaims Pro","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/acko-life-insurance/13-stand-alone-own-damage-private-car-policy-claim-form"}