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

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY ANSWER ALL QUESTION FULLY

BURGLARY CLAIM FORM

1. Name of Insured in full
2. Address
3. Occupation

4. a. Full Address of Premises broker into

b. The day and hour the Premises
were broker into

c. How the entrance was effected ?

d. Which rooms were entered ?

5. a. Whether the premises were inhabited at
the time of the Burglary ?

b. If not, for what periods have they been
Uninhabited since the last premium
Was due

6. a. When did you inform the Police
Authorities of the theft and at
Which Police Station

7. Whether you are the sole owner of the
property stolen ?

8. State the estimated value of the total
Contents of the premises at the time of
The Burglary.

1. For what sum you insure the contents
Against Fire and with which company ?

10. Are there any other insurance against Rs……………. In the………….. Insurance
Burglary upon the same property ? If so Company Policy No…………….
five full particulars Rs…………. In the ……………. Insurance
Company Policy No………….

11. Have you ever before sustained loss by
Fire or Burglary? If so give particulars.

I / We above named being insured under the above Policy do hereby declare and setforth that at or about_______________________ O' clock a.m. / p.m. on the ___________ 19 _____ a theft was committed at above described Premises in the manner stated and articles enumerated in the within list and valued at sum or Rs. _________________ were stolen therefrom and I / we further declare that no other person has any interest in the said property, as Owner Mortgage, Trustee or otherwise, and that it is not otherwise insured against Burglary, with this or any other Office, except as above stated.

Witness my hand this _______________ day of __________________________ 19____________

Witness
Occupation
Address Signature of Insured