Page 744 - The Central Motor Vehicles Rules, 1989

716 THE CENTRAL MOTOR VEHICLES RULES, 1989 ANNEXURE-XIII

FORM-XI
INSURANCE FORM
By Designated Officer of Insurance Company to Claims Tribunal
Within thirty (30) days of receipt of DAR

FIR No.
Date
Under Section
Police Station

1. Vehicle Details
Registration Number
Vehicle Make
Vehicle Model
2. Details of Insured

Name
Address
3. Policy Details
Policy No.
Period of Policy
Nature/Type of Policy
4. Date of Accident

5. Date of intimation of the accident by the
Insured to the Insurance Company
6. Date of receipt of FAR
7. Date of receipt of IAR
8. Date of receipt of DAR

9. Date of appointment of the Designated
Officer by the Insurance Company
10. Details of Designated Officer
Name
Address

11. Date of appointment of the
Surveyor/Investigator