The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

BURGLARY CLAIM FORM

1. Insured’s Name and Address
2. Occupation/Business Address
3. Address of the premises at which the loss occurred
(State whether private house, sale shop, flat, hotel etc.
Outbuilding thereof)
4 a) Date and Time of loss
b) When discovered and by whom
5. a) How was entry to the premises effected?
Was force used.
b) Which portion of the premises was entered?
(Give brief details of how exactly the loss occurred, also
specifying overleaf the articles stolen and property if any,
damaged)
6 a) Have the police been notified?
b) If so by whom & when and at what Police Station
c) If not state the reason for omission
7 a) Were the premises occupied at the Time of the loss?
b) If not on what date and at what hour were they last
occupied?
c) For how long have the premises been unoccupied since
the policy was effected or last renewed?
8 a) Is any body suspected of the theft?
b) If so please state full details.
9 If there is no evidence of theft or of forcible entry of the
premises has a thorough search been made for the
articles missing
10 a) Are you the sole owner of
i) the property lost or damaged?
ii) Of the premises?
b) Are you responsible for repairs to premises?
11 Have you ever before sustained loss by burglary,
housebreaking or theft?
(if so, please state particulars)
12 a) State the total value of property upon the premises at
the time of the loss
b) State the amount of Fire Insurance upon such property
and name of Company or Companies
13 Are you insure against the present loss under any other
Policy e.g. All Risks Passengers’ Baggage, Motor Car
Golfers etc.)
Issuing
Office
2
I hereby declare that all statements made on this form are true to the best of my knowledge and belief and
that the articles and property described belong to the persons named no other person have any interest
therein, whether as Owner, Mortgagee, Trustee or otherwise.
Place
Date Insured Signature…………….
A Burglary Policy being a contract of INDEMNITY all claims must be based upon the actual value of the
articles at the time of the Theft, due allowance being made for depreciation and tear.
Full description
of articles
stolen or
property
damaged
To whom the
articles or
property belonged
To whom purchased or
received Name and
Address
Date of
Purchased or
received
Cost
Rs. P
Deduction for
depreciation and wear
and tear
Rs. P
Total
Deduction
for
Depreciation
and wear &
Tear
Net Amount
Claimed