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

CLAIM FORM FOR BREAKDOWN OF DOMESTIC APPLIANCES

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

Policy No.
Claim No.
1. Name _______________________________________________________________

2. Address _________________________________________________________

_____________________________________________________________________

QUESTIONS ANSWERS
_____________________________________________________________________

1. When did the loss or damage occur ? (State Date & Hour)

2. Give the name and address of the witness to the occurrence.

3. What was damaged ?
a) Item of the Inventory a)

b) Sum Insured b)

c) Type of appliance c)

d) Name and year of manufacture d)
(Full details as on maker’s plate
to be given)

e) What is the cost of replacement
Of the machinery by a new machine
Of the same size and capacity

4. a) Was the domestic electric a)
appliance brand new or second
hand ?

b) What was the last occasion b)
before the damage when the
machine was overhauled or
attended to for maintenance
or damage

5. Is the damage to domestic electric appliance totally destroyed ?

6. Which parts of the appliance are damaged to such an extent that replacement of parts is necessary ?

7. Has the period of guarantee / warranty expired ? if so, when ?

8. What is the estimated amount of loss or damage ?

9. What was the cause of the damage and how did it occur ?
(This question must be answered in detail)

10. a) Has the appliance undergone any repairs previously ?

b) What was the nature of such repairs ?

11. Give the name and address of the person / workshop where repairs will be executed and surveyor etc. can inspect the item.

Provisional repairs will not be indemnified.

The undersigned policy holder declares to have answered the above questions conscientiously and truthfully and he is liable for the correctness and completeness of his statement.

DATE : ___________________ SIGNATURE : ___________________

Enclose : 1. Specification of Repairs form duly completed by the repairer.
2. Detailed Estimate from the repairer.
3. Original Purchase Bill / Invoice for the damaged item.