THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd & Head Office : New India Assurance Building,
87, Mahatma Gandhi Road, Bombay – 400 001

The issue of this form is not to be taken as an admission of liability
Policy No. ________________ Claim No.________________

AGRICULTURAL PUMPSET CLAIM FORM

Name: _______________________________________________________________

Address: ______________________________________________________________
____________________________________________________

Questions Answers

1. Situation of Pumping Sets?

2. When did the loss/damage occur?
(Give date and time)

3. Give names and address of any two
Witnesses to the occurrence.

4. a) Serial No. and type of Pumpset damaged.
b) Makers’ name and year of make.
c) Nature of damage Fire/Theft/Mech Breakdown
d) Is the item totally destroyed/lost? If not
what items are damaged?

5. Is the claimant the sole owner of the pumping
Set damaged or lost? If not state full particulars
Of any other interest.

6. Were there, at the time of the occurrence, any
Other insurance effected by the claimant or by any
other person on the Pumping Set? If so, state full
particulars.

7. Have you suffered any previous loss due to Fire/
Burglary/ Machinery Breakdown ? If so, state full
particulars.
8. What is the estimated amount of loss or damage?
Please submit repairers estimate in original.

IN CASE OF LOSS BY THEFT/BURGLARY

I. How was entrance effected into the premises?

II. Were the premises inhabited at the time of
Theft? If not, upon what date and at what hour were
They last inhabited prior to theft?

III. Have the Police Authorities been informed of
the theft ? If so, what is the Diary No and Date?
Has any arrest been made?

IN CASE OF DAMAGE BY ELECTRICAL/
MECHANICAL BREAKDOWN

I. When was the machine last overhauled or attended
To for maintenance or damage?

II. Has the manufacture ‘s Guarantee Period expired?
If so, when?

III. Has the Pump set been repaired previously?
If so, when and by whom?

IV. What was the cause of damage and how did it
Occur?

V. Name and address of the repairers carrying
Out the repairs.

IN CASE OF DAMAGE BY FIRE

What was the cause of the Fire, and under what
Circumstances did it occur?

The undersigned to have answered the above questions faithfully and he is liable for the correctness and completeness of his answers.

______________________
Date: __________________ Signature of claimant