Get Asian Alliance Claim Form

Asian Alliance Insurance PLC th 7 Floor Millennium House 46/58 Nawam Mawatha Colombo 02 Sri Lanka Reg. No. PQ31 Tel 94 11 2315555 Fax 94 11 2314400-1 E-mail info asianalliance. lk Website www. asianalliance. lk Motor Accident Report Form Vehicle No. Date and time of the Accident Policy No. Place of Accident Description of Name of Insured Telephone No. Name of Driver Driving License No. Date of Issue Authorized Classes Sketch of the accident Relationship to the Insured Use of vehicle at the time of accident Details of damages Details of third party Name of the police station accident reported Kindly note that as per section 161 of Motor Traffic Act you are required to report the accident forthwith to the nearest police station. I/ We hereby confirm and agree that a. All information and particulars given are true and complete and that no material has been withheld. b. All necessary assistance will be given to the Company in settlement of this claim. c. The only damage at present sustained by my/ our vehicle is solely as a result of the accident described herein and that no payment shall be due under the policy in respect of other damage repaired at the same time as a result of the accident described herein d. Asian Alliance Insurance PLC th 7 Floor Millennium House 46/58 Nawam Mawatha Colombo 02 Sri Lanka Reg* No* PQ31 Tel 94 11 2315555 Fax 94 11 2314400-1 E-mail info asianalliance. lk Website www. asianalliance. lk Motor Accident Report Form Vehicle No* Date and time of the Accident Policy No* Place of Accident Description of Name of Insured Telephone No* Name of Driver Driving License No* Date of Issue Authorized Classes Sketch of the accident Relationship to the Insured Use of vehicle at the time of accident Details of damages Details of third party Name of the police station accident reported Kindly note that as per section 161 of Motor Traffic Act you are required to report the accident forthwith to the nearest police station* I/ We hereby confirm and agree that a* All information and particulars given are true and complete and that no material has been withheld. b. All necessary assistance will be given to the Company in settlement of this claim* c* The only damage at present sustained by my/ our vehicle is solely as a result of the accident described herein and that no payment shall be due under the policy in respect of other damage repaired at the same time as a result of the accident described herein d. If any false or fraudulent claim be made by me/us or anyone acting on my/our behalf then all benefit under the policy may be forfeited* e. A representative of Asian Alliance Insurance PLC inspected the above damage vehicle and I/We hereby agree to repair the vehicle as per the Assessor s approval subject to the terms and conditions of the above motor policy. Asian Alliance Insurance PLC th 7 Floor Millennium House 46/58 Nawam Mawatha Colombo 02 Sri Lanka Reg* No* PQ31 Tel 94 11 2315555 Fax 94 11 2314400-1 E-mail info asianalliance. lk Website www. asianalliance. lk Motor Accident Report Form Vehicle No* Date and time of the Accident Policy No* Place of Accident Description of Name of Insured Telephone No* Name of Driver Driving License No* Date of Issue Authorized Classes Sketch of the accident Relationship to the Insured Use of vehicle at the time of accident Details of damages Details of third party Name of the police station accident reported Kindly note that as per section 161 of Motor Traffic Act you are required to report the accident forthwith to the nearest police station* I/ We hereby confirm and agree that a* All information and particulars given are true and complete and that no material has been withheld.