The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

ALL RISKS INSURANCE CLAIM FORM
(THIS FORM SHOULD BE COMPLED AND RETURNED TO THE COMPANY IMMEDIATELY)
1 Name and Address
2 Policy No.
3 Date of Loss/Accident
4 Description of Loss or Damage
5 Cause of Loss or Damage
6 If by Theft
a) Time and Day
b) How Committed
c) By whom discovered and when
d) Have Police been notified, If so, when
e) State result of Policy Investigation, if any
7 Are you insured against the present loss
Under any other Policy
I declare that foregoing statement are true to the best of my knowledge and belief, that the articles
and property described on the other side hereof were lost/stolen or damaged under the circumstance above
described, and that such articles and property belong to the person named, no other person having any
interest therein whether as owner, Mortgagee, Trustee or otherwise.
Place__________
Date__________
Insured’s Signature
All Risk Insurance Policy being a Contract of Indemnity, all claims must be based upon the actual value of
the articles at the time of loss, due allowance being made for wear and tear
Issuing
Office
2
Full description of
articles stolen or
property damaged
or lost
To whom the
articles or
property
belonged
From whom
purchased or
received
(Named and
Address)
Date of
purchased or
received
Cost Deduction for
wear and Tear
Sum claimed
being present
value