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

BANKER'S INDEMNITY INSURANCE
CLAIM FORM
(The Issue of this form is not to be taken as an admission of Liability)

Question to be answered by the Claimant

1. Name of Insured (in full)

2.
Address

3. How exactly did the loss occur?
Note:
i) Full and detailed particulars must be given and if this space is not sufficient a separate sheet giving the necessary particulars must be attached.
ii) A full and detailedstatement of all the transactions involved in the loss (stating their dates, nature and amount) must also be attached.

4.
When and how was the loss discovered?

5.
Give the names, occupations and address of all persons directly or indirectly connected with the loss.

6.
If any of your employee or employees is / are involved in the loss state what cash or other security of moneys if any, you hold from each of them.

7.
Give as many particulars as are known to you of the financial circumstances of each of the persons concerned in the loss.

8.
Do any of the persons involved hold any property? If so, give full particulars.

9.
Has the loss been reported to the Police? If so when and where? If not, why not?

Note: A copy of any statement made to the Police must be attached.

10.
What action have you or the Police taken in the matter with a view to recovering or minimizing the loss?

11.
Do you have other insurance covering the same risk? If so, give full particulars.

12.
Have you ever before sustained any loss of the same or similar nature? If so, give full particulars.

I/We the above named, do hereby to the best of my / our knowledge and belief warrant the truth of the foregoing statement in every respect and I / We agree that if I / We have made, or in any further declaration the Company may require in respect of the said loss shall make any false or fraudulent statement, or any suppression or concealment my / our claim shall be absolutely forfeited, and the Policy shall thenceforth be null and void.

Date : ……………………… Place …………………..

Signature of Claimant

Witness :

Address :