UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO 24 WHITES ROAD CHENNAI – 600 014

“ALL RISKS” CLAIM FORM
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
QUESTIONS TO BE ANSWERED BY THE CLAIMANT

POLICY NO.
CLAIM NO.
1. Name of Insured (in full)
2. Address
3. Occupation
4.
When & where did you last see the missing
property
5.
On what day and at what hour did you first
discover the loss or damages ?
6.
State (full particulars must be given) the
circumstances of the loss or damage
7.
If claim is in respect of jewellery, when was
the property last overhauled by a jeweler?
Give name & address of firm
8.
Have you informed the Police Authorities? If
so, when and where?
9.
Are you the sole owner of the property
damaged or stolen?
10.
Are there any other insurance upon the same
property? If so, give full particulars.
11.
Have you ever before sustained loss of the
same nature? If so, give particulars.
I/We the above named do declare and set forth that at or about_____________________o’clock
on the ________________________, the articles enumerated overleaf, and more particularly
described in the list lodged with the Company, were____________ and I/We do further declare
that no other person than myself / ourselves has/have an interest in the said property by Bill of
Sale, or as Owner, Mortgage Trustee, or otherwise, and that there is no further insurance except
as above mentioned, in this Company or any other company, whereof we claim the sum of
Rs._______________.
Witness my / our hand this_____________ day of ______________ 200 ____.
Signature of Insured________________
Witness (Sign.)
Name
Address
ALL RISKS CLAIM FORM
FULL
DESCRIPTION
OF STOLEN
ARTICLE
NAME &
ADDRESS OF
PARTY FROM
WHOM
ARTICLE
PURCHASED
OR BY WHOM
PRESENTED
DATE OF
PURCHASE OR
PRESENTATION
PRICE
PAID
DEDUCTION
FOR AGE,
USE
AND/OR
WEAR &
TEAR
SUM
CLAIMED
FOR
PRESENT
VALUE
ITEM NO. IN
THE LIST
ATTACHED
TO THE
POLICY
R E M A R K S
Signature of Insured________________