Accident to Vehicle Registration Number

Policy Number:

Policy Expiry Date:

Date of Accident:

IDV:

Estimated cost for repaires:

Is it a collision with another Vehicle:
YesNo

Has the claim includes any other Third Party Damage/Accident/Death etc ?:
YesNo

Has the incident has been reported to the Police?:
YesNo

Class of Vehicle:
Two WheelerPrivate CarCommercial Vehicle

Make/Variant:

Now the vehicle is at (Garage Address and Contact Number):

Intimated by(Name):

Garage Mobile number:

Customer Mobile number:

I understood that this link is only for the customers of SSV/myinsurer.in to intimate their Motor claims to Office. Intimating through this form is not to be taken as admission of any liability by office. Alternatively Registered Owner should have to submit the signed “Motor accident claim intimation” and “Motor claim form” in the office at the earliest along with required documents.