INITIAL CLAIM INTIMATION FORM
Name of Insured
Name of Insurance Company
Policy / Cover Note No.
Valid Upto
  (dd/mm/yyyy)
Reg No.
  (e.g.:DL4CM6910)
Make
Year Of Manufacture
Date & Time of Accident/Loss     
  dd/mm/yyyy 5:00PM
Place of accident
FIR Lodged Yes No
Any Third party loss Yes No
Not Known Yet
Driver at the time of accident
Workshop where the vehicle can be inspected
Phone No / Contact details of the workshop

INTIMATION
I/We wish to make a claim under the above mentioned policy. The details of the incident giving rise to the claim are as given above. Your representative may contact me/us or inspect the vehicle at the following address. Please issue the claim form and inform me/us of further procedures.

CONTACT DETAILS
Name
Address
City
State
Pin Code
Telephone No. - (Stdcode) - (Tele. No.)
Cell No.
Date (dd/mm/yyyy)
Please take a printout of the above intimation form and keep it with you as record.