{"id":867,"title":"MOTOR INSURANCE CLAIM FORM","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Claim%20Form_16_4.pdf","sha256":"12ad548cab0e0729e7f3e8db322dc5ba25d5dbaacd85bedd9934f6c074618264","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is for the insured to claim motor insurance for vehicle damage, theft, or third party claims.","notes":["Issue of this form does not imply acceptance of liability.","Claim form to be filled in and signed by the insured only."],"title":"MOTOR INSURANCE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"INSURED DETAILS","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-Mail Id","options":[],"required":null,"pdf_field":""},{"help":"Provide details if any other insurance policies cover this accident","type":"text","label":"Details of other existing Insurance policy (ies) in respect of this accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"LOSS DETAILS","fields":[{"help":"Enter date and time of the accident","type":"date","label":"Date & Time of Accident/ Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location where the loss occurred","type":"text","label":"Place of Loss","options":[],"required":null,"pdf_field":""},{"help":"Select the type of loss","type":"choice","label":"Type of Loss","options":["Damage","Theft","Third Party"],"required":null,"pdf_field":""},{"help":"Provide estimated repair cost","type":"amount","label":"Estimated Cost of Repairs","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe the accident or incident","type":"text","label":"Short Description of Accident/ Incident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DRIVER DETAILS","fields":[{"help":"Driver's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Driver's age","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Select the driver type","type":"choice","label":"Is Driver","options":["Owner","Paid Driver","Relative/Friend"],"required":null,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving License No","options":[],"required":null,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Valid up to","options":[],"required":null,"pdf_field":""},{"help":"Vehicle types driver is authorized to drive","type":"text","label":"Authorised to drive","options":[],"required":null,"pdf_field":""},{"help":"Authority that issued the license","type":"text","label":"Issuing Authority","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"ADDITIONAL DETAILS IN CASE OF COMMERCIAL VEHICLES","fields":[{"help":"Commercial vehicle permit number","type":"text","label":"Permit No.","options":[],"required":null,"pdf_field":""},{"help":"Permit expiry date","type":"date","label":"Valid Up To","options":[],"required":null,"pdf_field":""},{"help":"Authority issuing the permit","type":"text","label":"Issuing Authority","options":[],"required":null,"pdf_field":""},{"help":"Fitness certificate expiry date","type":"date","label":"Fitness Certificate Valid Up to","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers carried","type":"number","label":"No. of fare paying Passengers carried","options":[],"required":null,"pdf_field":""},{"help":"Details of goods carried","type":"text","label":"Weight and Nature of Goods Carried","options":[],"required":null,"pdf_field":""},{"help":"Goods Receipt / Lorry Receipt number","type":"text","label":"GR/LR No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"INJURY/DEATH DETAILS & POLICE REPORT","fields":[{"help":"Indicate if police report was filed","type":"choice","label":"Police Report Lodged","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide FIR or GD number if police report lodged","type":"text","label":"If yes, FIR/GD No.","options":[],"required":null,"pdf_field":""},{"help":"Name of police station where report was filed","type":"text","label":"Police Station Name","options":[],"required":null,"pdf_field":""},{"help":"Indicate if there was death, injury or property damage","type":"choice","label":"Death/Injury to any occupant / Third Party (others) and/or Third Party Property Damage","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if yes above","type":"text","label":"Details in case of Death and/or Injury to Third Party/Occupants/Driver or damage to property","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["photocopy of your blank / cancelled cheque for NEFT purpose"],"declarations":["The insured warrants the truth of the statements made in the form to the best of their knowledge.","If any false or fraudulent statement or concealment is made, the policy shall be void and claim rights forfeited.","The company reserves the right to verify facts and documents related to the policy and claim."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/national-insurance/867-motor-insurance-claim-form"}