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

Policy No. __________ Claim No. ___________

Notification of Loss or Damage for Contractor's All Risk Insurance

Claim No.
Title of contract insured :
Name(s) and address(es) of Insured(s).
Location and address of Contract Site:
Name of Supervising Engineer
Nearest Railway Station (Airport)
Advisable approach route to contract Site from railway station (airport) or otherwise
1 Which items were damaged ?
(a) Contract works
(b) Construction plant and equipment
(c) Construction machinery
2 When did the loss or damage occur?
(State date and exact time)
3 How did the damage occur and what was its probable cause ?
(Attach sketches, photos etc.)

4 How far had construction of the damaged item (s) progressed at the time of the occurrence of damage?
5 Give name and address of witness to the occurrence :
6 How will the damaged items be repaired.
7. Will any alterations or improvements be made to design, construction or material when repairs are carried out ?
8. What are the estimated costs for the repairs of damage to
(a) Contract Works?
(b) Construction plant and equipment ?
(c) Construction machinery?
9 Is Third Party Liability involved ?
10. Are existing buildings or surrounding property damaged ?
11 Remarks

The undersigned Insured declares to have answered the above questions conscientiously and truthfully.

Dated ________________ this _____________________ day of ________________________20_________

Signature ________________________________________________________________________________