{"id":14,"title":"TWO WHEELER CLAIM FORM","purpose":"claim","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/2024_05_15_Claim_Form_Two_Wheeler_Policy_Bundled_a5954b1f89.pdf","sha256":"c46afbc60327bf3a0347039f12522e4e6753e079701c03e3f156cac41bf465e9","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to file a claim for loss or damage to their two wheeler vehicle. The insured fills this form.","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 immediately and provide other details later.","Submit original documents for verification where specified.","For Electronic Fund Transfer, attach a blank cancelled cheque and PAN card copy of payee.","Submission of documents or bank details does not imply admission of liability by the company.","Terms and conditions for RTGS/NEFT payments apply as stated in the form."],"title":"TWO WHEELER CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. Details Of Insured / Claimant","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"If available, enter claim number","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance: To","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of insured","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pincode","type":"number","label":"Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone STD code","type":"number","label":"STD code","options":[],"required":false,"pdf_field":""},{"help":"Enter landline phone number","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail ID","options":[],"required":false,"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":true,"pdf_field":""},{"help":"Time of accident or theft with AM/PM","type":"text","label":"Time","options":["A.M","P.M"],"required":true,"pdf_field":""},{"help":"Location where accident or theft occurred","type":"text","label":"Location","options":[],"required":true,"pdf_field":""},{"help":"City of accident or theft","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of accident or theft","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Pincode of accident or theft location","type":"number","label":"Pincode","options":[],"required":true,"pdf_field":""},{"help":"Select the type of road where accident occurred","type":"choice","label":"Road Type","options":["Express Way","Hill Road","National / State Highway","City / Town Road","District Road","Other"],"required":true,"pdf_field":""},{"help":"Enter speed in kmph at time of accident","type":"number","label":"Speed at the time of acident kmph","options":[],"required":false,"pdf_field":""},{"help":"Select applicable type of loss","type":"choice","label":"Type of Loss","options":["Own Damage","Theft","Partial Theft","Third Party Death","Third Party Injury","Third Party Property Damage","Personal Accident"],"required":true,"pdf_field":""},{"help":"Describe purpose of vehicle use","type":"text","label":"Purpose for which the vehicle was being used at the time of accident / Theft","options":[],"required":true,"pdf_field":""},{"help":"Enter number of persons travelling","type":"number","label":"Number of persons travelling","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any other vehicle was involved","type":"yes-no","label":"Any other vehicle involved","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Name of person possessing keys if theft","type":"text","label":"In case of theft, keys in the possession of?","options":[],"required":false,"pdf_field":""},{"help":"Name of contact person at location","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Phone number of contact person","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of contact person","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Name of person at accident location","type":"text","label":"Contact Details of person/s at the Location - Name","options":[],"required":false,"pdf_field":""},{"help":"Relationship of contact person with insured","type":"text","label":"Relationship with Insured","options":[],"required":false,"pdf_field":""},{"help":"Phone number of contact person","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of contact person","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email of contact person","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Describe how the loss or accident happened","type":"text","label":"Describe cause of Loss / Damage / Accident","options":[],"required":true,"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":false,"pdf_field":""},{"help":"Indicate if FIR/DDR/GDR was filed","type":"yes-no","label":"FIR / DDR / GDR if any","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Explain reasons if FIR/DDR/GDR not filed","type":"text","label":"If not (reasons)","options":[],"required":false,"pdf_field":""},{"help":"Enter FIR/GDR/DDR number","type":"text","label":"Police FIR / GDR / DDR Details No.","options":[],"required":false,"pdf_field":""},{"help":"Date of FIR/GDR/DDR","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of police station","type":"text","label":"Police Station Name","options":[],"required":false,"pdf_field":""},{"help":"Date of police report","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"City of police station","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"State of police station","type":"text","label":"State","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Address of garage","type":"text","label":"Garage Address","options":[],"required":false,"pdf_field":""},{"help":"Name of contact person at garage","type":"text","label":"Garage Contact Person Name","options":[],"required":false,"pdf_field":""},{"help":"Phone number of garage","type":"phone","label":"Garage Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Email of garage","type":"email","label":"Garage Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"D. Vehicle Details","fields":[{"help":"Vehicle registration number","type":"text","label":"Reg. No.","options":[],"required":true,"pdf_field":""},{"help":"Vehicle make/brand","type":"text","label":"Make","options":[],"required":true,"pdf_field":""},{"help":"Vehicle model","type":"text","label":"Model","options":[],"required":true,"pdf_field":""},{"help":"Vehicle chassis number","type":"text","label":"Chassis No.","options":[],"required":true,"pdf_field":""},{"help":"Vehicle engine number","type":"text","label":"Engine No.","options":[],"required":true,"pdf_field":""},{"help":"Current odometer reading","type":"number","label":"Odometer Reading","options":[],"required":false,"pdf_field":""},{"help":"Vehicle color","type":"text","label":"Colour","options":[],"required":false,"pdf_field":""},{"help":"Date vehicle was registered","type":"date","label":"Date of Registration","options":[],"required":false,"pdf_field":""},{"help":"RTO jurisdiction of vehicle registration","type":"text","label":"RTO Jurisdiction","options":[],"required":false,"pdf_field":""},{"help":"Select vehicle class","type":"choice","label":"Vehicle Class","options":["Two wheeler","Private car","Others (specify)"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"E. Driver Details","fields":[{"help":"Full name of driver at time of accident","type":"text","label":"Name of Driver","options":[],"required":true,"pdf_field":""},{"help":"Driver's date of birth","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Relationship of driver to insured","type":"text","label":"Relationship with Insured","options":[],"required":false,"pdf_field":""},{"help":"Select driver's gender","type":"choice","label":"Gender","options":["Male","Female"],"required":false,"pdf_field":""},{"help":"Select driver's education qualification","type":"choice","label":"Qualification","options":["Below 10th Std.","10th Pass","12th Pass","Graduation","PG"],"required":false,"pdf_field":""},{"help":"Driver's telephone STD code","type":"number","label":"STD code","options":[],"required":false,"pdf_field":""},{"help":"Driver's phone number","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Driver's mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Driver's email address","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving License No.","options":[],"required":true,"pdf_field":""},{"help":"License issue date","type":"date","label":"Date of Issue","options":[],"required":false,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Date of Expiry","options":[],"required":false,"pdf_field":""},{"help":"RTO which issued license","type":"text","label":"Issuing RTO","options":[],"required":false,"pdf_field":""},{"help":"Select license type","type":"choice","label":"Type of License","options":["Permanent","Temporary"],"required":false,"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":false,"pdf_field":""}],"filled_by":"insured"},{"title":"F. Third Party Death / Injury / Personal Accident Details","fields":[{"help":"Serial number for each third party","type":"number","label":"SI No.","options":[],"required":false,"pdf_field":""},{"help":"Name of third party person","type":"text","label":"Name of person","options":[],"required":false,"pdf_field":""},{"help":"Indicate if third party was a passenger","type":"yes-no","label":"Whether TP passenger","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Address of third party","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Contact number of third party","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Describe death or injury type","type":"text","label":"Death / Type of Injury","options":[],"required":false,"pdf_field":""},{"help":"Hospital name if admitted","type":"text","label":"Name of Hospital where admitted","options":[],"required":false,"pdf_field":""},{"help":"Doctor attending third party","type":"text","label":"Name of Attending Doctor","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any legal notices","type":"text","label":"Details of any legal/Court Notice received","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Two wheeler insurance claims including own damage, theft, third party death/injury/property damage, and personal accident claims","attachments":["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)","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)","ORIGINAL BLANK CANCELLED CHEQUE signed by the Payee","PAN CARD copy of Payee"],"declarations":["The insured warrants the truth of all statements and understands that false or fraudulent statements will 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 claim processing."],"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/14-two-wheeler-claim-form"}