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BE TAKEN AS AN ADMISSION OF LIABILITY INSTRUCTIONS FOR FILLING THE FORM (a) Complete the form fully without leaving any relevant information. (b) Where check boxes provided tick the appropriate relevant box. (c ) Where multiple boxes, fill one letter per box CLAIM NUMBER (Office Use) POLICY NUMBER POLICY PERIOD From D D / M M Y / To Y D D / M M / Y : M M Y INSURED NAME INSURED'S ADDRESS Pincode Mobile Landline STD Code E-Mail Goods Vehicle VEHICLE TYPE Passenger.

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