{"id":1311,"title":"Motor OD Claim Form","purpose":"claim","insurer":{"slug":"united-india-insurance","name":"United India Insurance Company Limited"},"source_pdf":"https://uiic.co.in/web/sites/default/files/Policy-Document/Motor_OD_Claim_Form.pdf","sha256":"ef02cf758c47cc800206a703fb5b4959ef77787a37c4f2a758dff76ba14e159e","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim for own damage (OD) under their motor insurance policy after an accident or theft.","notes":["The issue of this form is not to be taken as Admission of Liability."],"title":"Motor OD Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured  Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-Mail:","options":[],"required":null,"pdf_field":""},{"help":"Enter your 12-digit Aadhar number","type":"text","label":"Aadhar No:","options":[],"required":null,"pdf_field":""},{"help":"Enter your PAN number","type":"text","label":"PAN No:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Bank Account Details","fields":[{"help":"Enter your bank account number for claim payment","type":"text","label":"Account No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of your bank branch","type":"text","label":"IFSC Code No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Vehicle Details","fields":[{"help":"Vehicle registration number","type":"text","label":"Registration No:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle manufacturer","type":"text","label":"Make:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle model","type":"text","label":"Model:","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":""}],"filled_by":"insured"},{"title":"Date & Place of Loss","fields":[{"help":"Date when the accident or theft occurred","type":"date","label":"Date of Loss:","options":[],"required":null,"pdf_field":""},{"help":"Time of loss with AM or PM","type":"text","label":"Time: A.M. / P.M.","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"Location where the accident or theft happened","type":"text","label":"Place of Accident / Theft:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Driver Details","fields":[{"help":"Name of the driver at time of loss","type":"text","label":"Driver Name:","options":[],"required":null,"pdf_field":""},{"help":"Driver's licence number and expiry date","type":"text","label":"Driving Licence No / Expiry Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Accident Details","fields":[{"help":"Briefly describe the accident","type":"text","label":"Provide brief description","options":[],"required":null,"pdf_field":""},{"help":"Number of occupants in the vehicle at time of accident","type":"number","label":"No of Occupants carried:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Workshop Details","fields":[{"help":"Workshop where vehicle is repaired","type":"text","label":"Name & Address of Workshop:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Workshop Mobile:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email:","options":[],"required":null,"pdf_field":""},{"help":"Estimated repair cost in rupees","type":"amount","label":"Estimate Amount: Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Theft Claim","fields":[{"help":"Indicate if the vehicle was stolen","type":"choice","label":"Theft of Vehicle: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of vehicle theft","type":"text","label":"Details :","options":[],"required":null,"pdf_field":""},{"help":"Indicate if accessories were stolen","type":"choice","label":"Theft of Accessories: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of accessories theft","type":"text","label":"Details :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"FIR Details","fields":[{"help":"Whether the incident was reported to police","type":"choice","label":"Accident/Theft reported to police: Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Police station where FIR was filed","type":"text","label":"Name of Police Station:","options":[],"required":null,"pdf_field":""},{"help":"Date when FIR was reported","type":"date","label":"Date of reporting to Police:","options":[],"required":null,"pdf_field":""},{"help":"FIR or crime diary number","type":"text","label":"FIR/Crime diary number:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Third Party Loss Details","fields":[{"help":"Indicate if driver was injured or died","type":"choice","label":"Any Injury/Death to Driver: Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of driver injury or death","type":"text","label":"Details:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if third party was injured or died","type":"choice","label":"Any TP Injury/Death: Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of third party injury or death","type":"text","label":"Details:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any occupant was injured or died","type":"choice","label":"Any Injury/Death to Occupant: Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of occupant injury or death","type":"text","label":"Details:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if third party property was damaged","type":"choice","label":"Any TP Property Damage: Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of third party property damage","type":"text","label":"Details:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing the declaration","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured or claimant","type":"signature","label":"Signature of Insured / Claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The insured declares that all statements made are true to the best of their knowledge and belief.","The insured agrees that any false or fraudulent statement or concealment will void the policy and forfeit all rights to claim."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"mayfair.claims@mayfairwecare.com","label":"Overseas Mediclaim Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Worldwide - Excluding USA & Canada -","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"mayfairassist@mayfairwecare.com","label":"Overseas Mediclaim Medical Emergency Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"://www.mayfairwecare.com/contact/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Wor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18004190133","label":"Overseas Mediclaim Policy Toll-Free Number (India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"l - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact/\nWebsite\nhttps://w","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18888811701","label":"Overseas Mediclaim Policy Toll-Free Number (United States)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"ss\nTower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Loc","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08083045211","label":"Overseas Mediclaim Policy Toll-Free Number (United Kingdom)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"nowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please v","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18885192693","label":"Overseas Mediclaim Policy Toll-Free Number (Canada)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"annerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.may","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8003211710","label":"Overseas Mediclaim Policy Toll-Free Number (Singapore)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"lore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001236889","label":"General Contact Number","level":null,"hours":null,"applies_to":"all","source_url":"https://uiic.co.in/web/","quote":"Links\nCustomer Portal\nKYC Process\nFacebook\nInstagram\nYoutube\nTwitter\nOffice Locator\nIntermediary Portal\nDigi Locker\ntel:18001236889","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/united-india-insurance/1311-motor-od-claim-form"}