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Format of Affidavit for Consumer Case for Vehicle Insurance Claim

Format of Affidavit for Consumer Case for Vehicle Insurance Claim

Format of Affidavit for Consumer Case for Vehicle Insurance Claim


Complaint No._____ of _____ Under Consumer Protection Act

_____                                   …..Complainant
_____                                   …..Respondents

Complaint under section _____ of the consumer Protection Act, _____


I, _____ son of _____ resident _____ at present Resident of _____ do hereby solemnly affirm and declare as under:-

1-    That the deponent is the consumer of the respondent as defined under the consumer protection Act, _____.

2-    That the deponent is the registered owner of the vehicle _____ bearing its Registration No. _____ Engine No. _____, Chassis No. _____, Model _____. The said vehicle was get insured by the deponent with the respondent insurance company vide insurance policy No. _____ which was valid with effect from _____ to midnight of _____ covering all type of risks therein. As per the insurance policy issued by the respondent to the deponent , the said vehicle was get insured for the amount  of _____/- (_____) . A photocopy of the insurance policy and a photocopy of Registration Copy of _____ No. _____ are exhibited herewith as _____.

3-    That at the time of issuance of the above said insurance policy, the respondent had assured the deponent that the respondent would pass insurance claimed and make the payment of the claimed amount immediately, if the said vehicle will meet with accident or will be stolen at any point of time with  in the validity period of the said insurance policy .

4-    That in the mid night of _____ at about _____. The deponent parked his above said _____ in front of _____ in _____, but the said vehicle was stolen by someone in the night of _____. The deponent searched the said vehicle everywhere, but the where about of the said vehicle were not traced by the deponent. Hence the deponent got registered the FIR in the police station _____ bearing its FIR  No. _____, dated _____ U/S. _____IPC regarding the theft of the said _____ against unknown thief. The copy of the FIR is exhibited herewith as _____.

5-    That just after the steeling of the said vehicle of the deponent intimated the respondent and also submitted the FIR and all the relevant documents to the respondent regarding the steeling of the said vehicle.

6-    That then after the deponent approached the respondent and requested to make the payment of the insured amount by raising the insurance claim in the office of the respondent. In this regard the respondent had issued the claim no. _____ and the respondent demanded the copy of the untraced  report or final report from the deponent on _____.

7-    That upon the application of the deponent the Hon’ble court of _____, has declared the above-mentioned vehicle as untraced vide its order dated  _____. The copy of the order dated _____ is exhibited herewith as _____.

8-    That then after the deponent personally visited the office of the respondent and met with the respondent and again approaching for claim in writing and submitted the final report along with the copy of the untraced report, photocopy of insurance policy , copy of the FIR, NCR  Report, and copy of the R.C. of the said vehicle vide application dated _____.

9-    That the respondent being the insurer of the above mentioned vehicle of the deponent and the above said  vehicle has been stolen in the validity period of insurance policy, hence the respondent is liable and duty bound to pay the insurance claim as per the terms and conditions of the said policy to the deponent as soon as, but the respondent is trying to escape from their responsibility and liability to make the payment of the claimed amount to the deponent in arbitrary manner, hence the deponent  is legally entitled to recover the amount of insurance claim along with interest from the respondent as per the terms and conditions of the insurance policy .

10-    That the cause of action to file the present complaint accrued on each and every date when the deponent requested the respondent to make the payment of the insurance claimed amount and the cause of action finally accrued on _____ when the respondent has finally refused to make the payment of the insurance claimed amount to the deponent.

11-    That the relevant documents which are produced before this Hon’ble Forum may kindly be read in my evidence.



Verified that the above contents of this affidavit are true and correct to the best of my knowledge and belief and nothing has been concealed therein
Verified at _____ on _____


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