{"id":887,"title":"National Stand Alone Compulsory Personal Accident Cover (Owner-Driver) under Motor Policies","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/SA%20CPA%20Claim%20Form_0.pdf","sha256":"65fba5d51f3d0b13aafbc2962e0aaa21b48d1c2a19d369c1b2c38b19579d1f0a","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim under the compulsory personal accident cover for owner-drivers under motor policies.","notes":["The claim form must be filled and signed by the insured only.","Issue of this form does not imply acceptance of liability."],"title":"National Stand Alone Compulsory Personal Accident Cover (Owner-Driver) under Motor Policies","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":"Claim No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Full postal address of the insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Contact email address","type":"email","label":"E-Mail Id","options":[],"required":null,"pdf_field":""},{"help":"List any other insurance policies related to 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":"Date and time when the accident occurred","type":"date","label":"Date & Time of Accident/ Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location where the accident happened","type":"text","label":"Place of Loss","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":"Name of the driver at the time of accident","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Age of the driver","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Select the appropriate relationship of the driver to the vehicle","type":"choice","label":"Is Driver:","options":["Owner","Paid Driver","Relative/ Friend"],"required":null,"pdf_field":""},{"help":"Owner's driving license number","type":"text","label":"Driving License No. of Owner","options":[],"required":null,"pdf_field":""},{"help":"Expiry date of the driving license","type":"date","label":"Valid up to","options":[],"required":null,"pdf_field":""},{"help":"Specify who is authorized to drive the vehicle","type":"text","label":"Authorised to drive","options":[],"required":null,"pdf_field":""},{"help":"Authority that issued the driving license","type":"text","label":"Issuing Authority","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"ADDITIONAL DETAILS IN CASE OF COMMERCIAL VEHICLES","fields":[{"help":"Permit number for commercial vehicle","type":"text","label":"Permit No.","options":[],"required":null,"pdf_field":""},{"help":"Expiry date of the permit","type":"date","label":"Valid Up to","options":[],"required":null,"pdf_field":""},{"help":"Expiry date of the fitness certificate","type":"date","label":"Fitness Certificate Valid Up to","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers carried for fare","type":"number","label":"No. of fare paying Passengers carried","options":[],"required":null,"pdf_field":""},{"help":"Details of goods carried including weight and type","type":"text","label":"Weight and Nature of Goods Carried","options":[],"required":null,"pdf_field":""},{"help":"Goods Receipt or 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 a police report was filed","type":"yes-no","label":"Police Report Lodged","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"FIR or GD number if police report was lodged","type":"text","label":"If yes, FIR/GD No.","options":[],"required":null,"pdf_field":""},{"help":"Name of the police station where report was filed","type":"text","label":"Police Station Name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place where the declaration is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of the Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Compulsory Personal Accident Cover (Owner-Driver) under Motor Policies","attachments":[],"declarations":["The insured warrants the truth of the statements made in the form to the best of their knowledge and belief.","If any false or fraudulent statement or concealment is made, the policy shall be void and rights to recover will be 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/887-national-stand-alone-compulsory-personal-accident-cover-owner-driver-under-motor"}