{"id":19,"title":"MOTOR INSURANCE CLAIM FORM","purpose":"claim","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/2023_09_12_Claim_Form_Stand_Alone_Own_Damage_Two_Wheeler_Policy_3d2859d315_dc0fabbe5c.pdf","sha256":"0f583edc39ca565c7280d1ea86ecb68a8abccb1c97cd75683bb1683414c73497","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for filing a motor insurance claim by the insured person for damages or losses related to their vehicle.","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 particulars later.","Attach original documents for verification where specified.","Submission of documents or bank details does not imply admission of liability by the company.","Use the provided list of documents as a guide for claim settlement.","For Electronic Fund Transfer, attach an original blank cancelled cheque signed by the payee and PAN card copy.","The RTGS/NEFT facility will be activated within 15 days of receipt of the mandate form.","The insured agrees to indemnify the company against claims arising from RTGS/NEFT transactions.","Notices and changes to terms will be communicated via hand delivery, email, website, or post.","Legal jurisdiction for disputes is Mumbai courts."],"title":"MOTOR INSURANCE 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":"Fill in capital letters","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Pincode","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"STD code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Details Of Loss / Damage / Accident / Theft","fields":[{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Select A.M or P.M","type":"text","label":"Time","options":["A.M","P.M"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Location","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Pincode","options":[],"required":true,"pdf_field":""},{"help":"Select one; specify if Other","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","type":"number","label":"Speed at the time of acident","options":[],"required":false,"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":true,"pdf_field":""},{"help":"","type":"text","label":"Purpose for which the vehicle was being used at the time of accident / Theft","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Number of persons travelling","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Any other vehicle involved","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"In case of theft, keys in the possession of?","options":[],"required":false,"pdf_field":""},{"help":"Name of key holder if theft","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Contact Details of person/s at the Location - Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Describe in detail","type":"text","label":"Describe cause of Loss / Damage / Accident","options":[],"required":true,"pdf_field":""},{"help":"Draw and describe location 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":true,"pdf_field":""},{"help":"Indicate if FIR or DDR or GDR filed","type":"yes-no","label":"FIR / DDR / GDR if any","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain if no FIR/DDR/GDR","type":"text","label":"If not (reasons)","options":[],"required":false,"pdf_field":""},{"help":"","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":"","type":"text","label":"Police Station Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Garage Details","fields":[{"help":"","type":"text","label":"Garage Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Garage Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Garage Contact Person Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Garage Phone No.","options":[],"required":false,"pdf_field":""},{"help":"","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 manufacturer","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":"","type":"date","label":"Date of Registration","options":[],"required":false,"pdf_field":""},{"help":"","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":"","type":"text","label":"Name of Driver","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Qualification","options":["Below 10th Std.","10th Pass","12th Pass","Graduation","PG"],"required":false,"pdf_field":""},{"help":"","type":"number","label":"STD code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Driving License No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Issue","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Expiry","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Issuing RTO","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Type of License","options":["Permanent","Temporary"],"required":false,"pdf_field":""},{"help":"","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":"Provide details if any legal or court notice received","type":"text","label":"Details of any legal/Court Notice received","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of Insured / Claimant","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"","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":true,"pdf_field":""},{"help":"","type":"text","label":"Payee Name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Payee Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account","options":["Saving","Current","Other"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code of the Bank","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"MICR Code No. of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Attach PAN card copy","type":"text","label":"Permanent Account Number (PAN) of Payee","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Comprehensive car insurance policy, Comprehensive bike insurance policy, Third party car insurance policy, Third party bike insurance policy","attachments":["ORIGINAL BLANK CANCELLED CHEQUE signed by the Payee","PAN CARD copy of Payee","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"],"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 that non-fulfillment may delay claim settlement.","The insured agrees to provide additional information and authorizes the company to access relevant information for the claim."],"dropped_labels":2},"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/19-motor-insurance-claim-form"}