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

BHAGYASHREE CHILD WELFARE CLAIM FORM

The issue of this form is not to be taken as an Admission of liability
CLAIM NO._____________________________________________

SECTION I (TO BE FILLED IN FOR ALL CLAIMS)

1. (a) Insured’s Name __________________________________

(b) Address: ____________________________________
____________________________________
____________________________________
____________________________________

(c) Date of birth: ____________________________________
(enclose birth certificate)

(d) Age: ____________________________________

(e) Name of the school where the insured is studying________
_____________________________________

(f) Class of study: ____________________________________

2. (a) Name of Father: ___________________________________
(b) Occupation of Father: _______________________________
(c) Age of Father: ____________________________________
(d) Name of Mother: __________________________________
(e) Occupation of Mother: ______________________________
(f) Age of Mother: ____________________________________

3. (a) Policy No. ________________________________________
(b) Period From ________________to ____________________
(c) Issued at _________________________________________

4. (a) Name of deceased: _________________________________
(b) Relationship with Insured: ___________________________
(c) Particulars of Accident: ______________________________
(d) Date of Accident: __________________________________
(e) Time of Accident: __________________________________
(f) Place of Accident: __________________________________
(g) Whether reported to police Yes/No, P. S. case No.: ______
(h) Details of cause of death: ____________________________
______________________________________________________________________________________________________

5. (a) Whether parent removed to hospital immediately after
accident: _______________________________________
(b) If yes, address of the hospital: _______________________

6. (a) Do you have any other similar policy? Yes/ No
(i) If yes, Name of the company: _________________
(ii) Policy No.: ________________________________
(iii) Period ____ yrs From __________ to _____________
(iv) Issuing office at: ______________________________

I declare that I have __________ Nos. of female child/ children and I have taken this policy for the benefit of my female child named above and further declare that I have not taken any BHAGYASHREE CHILD WELFARE POLICY in respect of other female children.

I/we the above name do hereby declare to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect and I/we agree that I/we have made, or in any further declaration which the company may required in respect of the said accident, shall make any false or fraudulent statements or any suppression or concealment the policy shall be void and all rights to recover thereunder in respect of past or future accident shall be forfeited.

Date ____________ _________________________

Signature of witness ____________ (Signature of the Parent/Guardian)

SECTION II (TO BE FILLED IN BY HOSPITAL AUTHORITIES)

1. Name and address of the hospital: __________________________________
______________________________________________________________

2. Date of admission: ______________________________________________
3. Date of death: _________________________________________________
4. Cause of death: ________________________________________________
5. Extent of injuries: ______________________________________________
6. Date of postmortem: ____________________________________________

Date ____________
Rubber Stamp of Hospital Signature of the Competent Authority
Of Hospital/Nursing Home