{"id":996,"title":"MOTOR VEHICLE CLAIM FORM","purpose":"claim","insurer":{"slug":"new-india-assurance","name":"The New India Assurance Company Limited"},"source_pdf":"https://www.newindia.co.in/assets/docs/know-more/motor/CLAIM%20FORM%20NIACL%20MOTOR%20OD%20STANDARD%20%20AS%20PER%20HO%20TEMPLATE%20%281%29.pdf","sha256":"1ee0caa889f89f64edd71ed3a6c768b7bcf63816c975309fdfdb4e7b00a6c945","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured policyholder to claim for damages or losses related to a motor vehicle accident or theft.","notes":["Only the insured can sign this claim form.","Please enclose the estimated cost of repairs of the insured vehicle."],"title":"MOTOR VEHICLE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claim and Policy Details","fields":[{"help":"","type":"text","label":"Claim No","options":[],"required":null,"pdf_field":""},{"help":"Date and time when the claim was intimated","type":"date","label":"Date & Time of Initmation","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy or cover note number","type":"text","label":"Policy No. / Cover Note No.","options":[],"required":true,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of insurance","options":[],"required":true,"pdf_field":""},{"help":"Full name, address, mobile number and email of the insured","type":"text","label":"Name of the Insured & Address,Mobile No & e-mail ID","options":[],"required":true,"pdf_field":""},{"help":"Name, mobile number and email ID of the garage where vehicle is kept","type":"text","label":"Name of the garage and contact details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Accident / Theft","fields":[{"help":"Date of the accident or theft","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Time of the accident or theft","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"Location where the accident or theft occurred","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"First Information Report number and date if filed","type":"text","label":"FIR No. & Date","options":[],"required":null,"pdf_field":""},{"help":"Section under which FIR was registered","type":"text","label":"Charges u/s:","options":[],"required":null,"pdf_field":""},{"help":"Name of the police station where FIR was lodged","type":"text","label":"Police Station","options":[],"required":null,"pdf_field":""},{"help":"Vehicle number(s) of other involved vehicles","type":"text","label":"In case other Vehicle(s) is/are involved/ responsible, specify vehicle No(s)","options":[],"required":null,"pdf_field":""},{"help":"Insurance policy details of other involved vehicle(s)","type":"text","label":"Policy details of that Vehicle(s)","options":[],"required":null,"pdf_field":""},{"help":"Name of the person who filed the FIR","type":"text","label":"Name of the Complainant, who lodged the FIR","options":[],"required":null,"pdf_field":""},{"help":"Purpose of vehicle use at time of accident","type":"text","label":"For what purpose was the vehicle being used at the material time?","options":[],"required":true,"pdf_field":""},{"help":"Short description of the accident","type":"text","label":"Brief particulars of the accident","options":[],"required":true,"pdf_field":""},{"help":"Explain if FIR was delayed or not filed","type":"text","label":"FIR: Specify the reasons for delayed FIR or not lodging an FIR.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"The Insured Vehicle Particulars","fields":[{"help":"Vehicle registration number","type":"text","label":"Regd. No.","options":[],"required":true,"pdf_field":""},{"help":"Vehicle manufacturer","type":"text","label":"Make","options":[],"required":true,"pdf_field":""},{"help":"Year of manufacture","type":"number","label":"Year","options":[],"required":true,"pdf_field":""},{"help":"Engine number of the vehicle","type":"text","label":"Engine No.","options":[],"required":true,"pdf_field":""},{"help":"Chassis number of the vehicle","type":"text","label":"Chasis No.","options":[],"required":true,"pdf_field":""},{"help":"Engine cubic capacity or carrying capacity","type":"text","label":"Cubic / Carrying Capacity","options":[],"required":null,"pdf_field":""},{"help":"Select if occupants or pillion riders were present","type":"choice","label":"For Private Vehicle: Whether Occupant(s) / Pillion - Rider(s) was / were carried at the material time of accident? Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of passengers or witnesses","type":"text","label":"Give name and addresses, contact Tel. No. of passangers/other witnesses if any","options":[],"required":null,"pdf_field":""},{"help":"Registered laden weight in kilograms","type":"number","label":"For Commercial Vehicle: Regd. Laden Weight: Kgs.","options":[],"required":null,"pdf_field":""},{"help":"Unladen weight in kilograms","type":"number","label":"Unladen Weight: Kgs.","options":[],"required":null,"pdf_field":""},{"help":"Weight of goods carried in kilograms","type":"number","label":"Weight of Goods Carried Kgs.","options":[],"required":null,"pdf_field":""},{"help":"Type of vehicle permit","type":"text","label":"Type of Permit:","options":[],"required":null,"pdf_field":""},{"help":"Description of goods carried","type":"text","label":"Nature of Goods carried","options":[],"required":null,"pdf_field":""},{"help":"Details of persons carried in goods vehicle","type":"text","label":"Person Carried in Goods Vehicle","options":[],"required":null,"pdf_field":""},{"help":"Select if public liability policy is taken","type":"choice","label":"Whether Public Liability Policy is taken (For dangerous / Hazardous Goods). Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Policy number and validity if public liability policy is taken","type":"text","label":"If yes, specify Policy No. & validity period","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers carried in public service vehicle","type":"number","label":"No. of Passengers carried in case of PSV at the material time of accident:","options":[],"required":null,"pdf_field":""},{"help":"Number of passengers permitted by permit","type":"number","label":"No. of Passengers permitted under Permit:","options":[],"required":null,"pdf_field":""},{"help":"Specify if vehicle has trailers attached and their numbers","type":"text","label":"Whether the vehicle attached with Trailer(s)? Yes / No, If Yes, specify No(s).:","options":[],"required":null,"pdf_field":""},{"help":"Policy or cover note numbers for trailers if any","type":"text","label":"Policy / Cover note Nos","options":[],"required":null,"pdf_field":""},{"help":"Insurance period for trailers if any","type":"text","label":"Period of insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Injury / Death to Third Party / Employees / Damage to Third Party Property","fields":[{"help":"Number of persons injured and died","type":"text","label":"Specify No. of Persons Injured / Died : Injured: No.: Death: No.:","options":[],"required":null,"pdf_field":""},{"help":"Select if any workman was injured or died","type":"choice","label":"Whether any of your Workman sustained injury / death: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Number of workmen injured and died","type":"text","label":"Injured: No.: Death: No.:","options":[],"required":null,"pdf_field":""},{"help":"Wages paid to injured or deceased workmen","type":"text","label":"Specify the wages paid to the concerned Workman/men:","options":[],"required":null,"pdf_field":""},{"help":"Description of damage to third party property","type":"text","label":"Specify, the nature of damage to TPPD:","options":[],"required":null,"pdf_field":""},{"help":"Estimated cost of third party property damage","type":"amount","label":"Approximate Cost of TPPD damage: Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Driver on the Wheel, at the Material Time of Accident","fields":[{"help":"Full name and address of the driver","type":"text","label":"Name & Address of the Driver","options":[],"required":true,"pdf_field":""},{"help":"Driver's age","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Select relationship of driver to insured","type":"choice","label":"Relationship with Insured: Put 'X' Mark Self Own Paid Driver Relation / Friend/ Other","options":["Self","Own Paid Driver","Relation / Friend","Other"],"required":true,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving Licence No.:","options":[],"required":true,"pdf_field":""},{"help":"Authority that issued the driving license","type":"text","label":"Issuing Authority:","options":[],"required":null,"pdf_field":""},{"help":"Types of vehicles driver is authorized to drive","type":"text","label":"Specify, type(s) of Motor Vehicle(s) Authorised to drive:","options":[],"required":null,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Date of expiry:","options":[],"required":null,"pdf_field":""},{"help":"List issuing and renewing authorities in order","type":"text","label":"Specify, Original issuing Authority and subsequent renewing Authorities in chronological order: 1 2 3 4","options":[],"required":null,"pdf_field":""},{"help":"Select if license was ever suspended","type":"choice","label":"Whether the Driving Licence is / was suspended any time by the Competent Authority / Court : Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of license suspension if any","type":"text","label":"If yes, give details:","options":[],"required":null,"pdf_field":""},{"help":"Details of previous accidents in last 5 years","type":"text","label":"Has the driver had any previous accidents in the five years, if yes give details:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Damage to Insured Vehicle","fields":[{"help":"Date, time and place for vehicle inspection","type":"text","label":"When & where the damaged vehicle can be inspected:","options":[],"required":true,"pdf_field":""},{"help":"Describe the damage to the vehicle","type":"text","label":"Nature & Description of the Damage to the insured Vehicle","options":[],"required":true,"pdf_field":""},{"help":"Insured Declared Value of the vehicle","type":"amount","label":"IDV : Rs.","options":[],"required":null,"pdf_field":""},{"help":"Estimated repair cost (attach estimate)","type":"amount","label":"Approximate Estimated Cost of repairs: Rs.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Only the insured can sign this claim form","type":"signature","label":"*Signature of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"motor vehicle insurance claims","attachments":["Estimated Cost of repairs of the insured vehicle"],"declarations":["The insured warrants the truth of the statements made in this form to the best of their knowledge and belief.","If any false or fraudulent statement, suppression or concealment of fact is made, the policy shall be void and all rights to recover shall be forfeited."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"nia.[office code]@newindia.co.in","label":"Email for Claim Intimation (replace [office code] with actual code)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/Customer%20Information%20Sheet%20%28CIS%29%20Two%20Wheeler%20Package%20Policy.pdf","quote":"laim to The New India Assurance Co Ltd via– • Website – www.newindia.co.in • Toll Free Number – 1800-209-1415 • Email – nia.[office code]@newindia.co.in • Details of procedure to be followed for cashless service as well as for reimbursement of claim • Intimation of claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-209-1415","label":"Toll Free Number for Claims Intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/Customer%20Information%20Sheet%20%28CIS%29%20Two%20Wheeler%20Package%20Policy.pdf","quote":"claimant may intimate claim to The New India Assurance Co Ltd via– • Website – www.newindia.co.in • Toll Free Number – 1800-209-1415 • Email – nia.[office code]@newindia.co.in • Details of procedure to be followed for cashless service as well as for re","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/new-india-assurance/996-motor-vehicle-claim-form"}