The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

“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________________