{"id":937,"title":"COMPULSORY PERSONAL ACCIDENT (OWNER-DRIVER) UNDER MOTOR INSURANCE POLICIES CLAIM FORM","purpose":"claim","insurer":{"slug":"navi-general-insurance","name":"Navi General Insurance Limited"},"source_pdf":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviInsurance/NaviCompulsoryPersonalAccidentPolicy/2020-2021/January/NaviCompulsoryPersonalAccidentPolicy%20Claim%20form.pdf","sha256":"e69e141a4adb40ac61fff7e1828a03a8a6e3838003048a327616b067ee66672e","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is for claiming compensation under the compulsory personal accident cover for owner-drivers under motor insurance policies. It is filled by the insured or claimant.","notes":["Fill the form completely.","The issue of this form is not an admission of liability."],"title":"COMPULSORY PERSONAL ACCIDENT (OWNER-DRIVER) UNDER MOTOR INSURANCE POLICIES CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Policy Holder","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Claim No.:","options":[],"required":false,"pdf_field":""},{"help":"Full name of the insured or claimant","type":"text","label":"Insured / Claimant’s Name:","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":true,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin Code:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.:","options":[],"required":true,"pdf_field":""},{"help":"Optional landline number","type":"phone","label":"Landline No.:","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Loss Details","fields":[{"help":"Date when the accident occurred (DD/MM/YYYY)","type":"date","label":"Date of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Time of accident with AM/PM","type":"text","label":"Time of Loss :","options":[],"required":true,"pdf_field":""},{"help":"Location where the accident happened","type":"text","label":"Place of Loss :","options":[],"required":true,"pdf_field":""},{"help":"Brief description of the accident and loss","type":"text","label":"Description of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Registration number of the vehicle involved","type":"text","label":"Vehicle Registration Number:","options":[],"required":true,"pdf_field":""},{"help":"Chassis number of the vehicle","type":"text","label":"Chassis No.:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Details of Insured’s Driving License","fields":[{"help":"Full name with title","type":"text","label":"Name of Driver: Mr./Ms./Mrs.","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Driving license number","type":"text","label":"Driving License (DL) No.:","options":[],"required":true,"pdf_field":""},{"help":"Name of the Regional Transport Office that issued the license","type":"text","label":"Issuing RTO:","options":[],"required":true,"pdf_field":""},{"help":"Vehicle types authorized to drive","type":"text","label":"Authorized to Drive:","options":[],"required":true,"pdf_field":""},{"help":"License expiry date (DD/MM/YYYY)","type":"date","label":"Valid up to:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Police Notification Details","fields":[{"help":"Indicate if police report was filed","type":"yes-no","label":"Police report lodged:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Police report number if applicable","type":"text","label":"If Yes, Report No.:","options":[],"required":false,"pdf_field":""},{"help":"Date of police report (DD/MM/YYYY)","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"Name of police station where report was lodged","type":"text","label":"Police Station:","options":[],"required":false,"pdf_field":""},{"help":"District of the police station","type":"text","label":"District:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Injury Details","fields":[{"help":"Select the nature of injury sustained","type":"choice","label":"Nature of Injury:","options":["Permanent Disablement","Partial Disablement","Death"],"required":true,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"Declaration","fields":[{"help":"Date of signing the declaration (DD/MM/YYYY)","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Signature of the claimant or nominee","type":"signature","label":"Signature of Insured / Nominee","options":[],"required":true,"pdf_field":""},{"help":"Place where the form is signed","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / claimant"}],"deadlines":[],"applies_to":"Compulsory Personal Accident (Owner-Driver) under Motor Insurance Policies","attachments":[],"declarations":["The claimant agrees to provide additional information if required by the company.","False or fraudulent statements or concealment will void the policy and forfeit claim rights.","The company reserves the right to verify facts and documents related to the claim.","Consent is given to the company to collect, retain, and share personal and sensitive information for servicing the policy and claim.","The claimant may update or withdraw consent for information sharing, understanding that withdrawal may affect service provision."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"insurance.help@navi.com","label":"Claims intimation","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"own damage claim\n12 | Policy Servicing Claim Intimation and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcare@navi.com","label":"Email for Senior Citizens","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"on and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk in for assistance 6. Dispatch your letters to us a","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 123 0004","label":"Toll Free","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"nses - paid amount under own damage claim\n12 | Policy Servicing Claim Intimation and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.n","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"url","value":"https://www.naviinsurance.com/service/","label":"Customer Portal on website","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk in for assistance 6. Dispatch your letters to us at – Corporate Office: Navi General Insurance Limited, Vaishna","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/navi-general-insurance/937-compulsory-personal-accident-owner-driver-under-motor-insurance-policies-claim-f"}