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

Notification of Loss or Damage for Policy No.
Electronic Equipment Insurance Claim No.

The issuing of this form is not to be taken as an admission of liability by the Insurers.
1. Name and Address
of Insured
Location of the object

Leading Insurer

Period

Last Premium Payment

2. When did the loss or Time : Date :
damage occur ?

When was notice first given To whom ?
to the Insurer?
By whom ?

3. Are there any witnesses ?  Yes  No

If so, please give names,
Professions and addresses.

1. Name and address of surveyor

5. Which item was damaged ?1

Item No. in Specification
of Policy Schedule

Sum insured

Name of manufacturer,
type of machine

Year of manufacture, serial
number
(Please give full details as
on manufacturer's plate).

Description of damaged
Item (capacity, r.p.m.,
Weight, etc.)

6. Are the damaged items If so, with which?
also insured with another
company?

Scope of cover

If more than one scheduled items affected, please complete one form per item.

7. How did the damage occur
and what was the probable
cause ?

Please attach sketches,
photos, etc.

Where damage to EDP
systems is involved, please
furnish a loss report drawn
up by the maintenance firm
or supplier

8. In the event of damage to Age in months
tubes or valves for X-ray
equipment.
Previous usage (No. of shots)

Hours of operation (for depth therapy)
9. In the event of losses Which police station did you notify of the incident?
caused by burglary, theft,
fire, traffic, accidents.

File reference used by Public Prosecutor's Office
10. In the event of damage to Serial No. of damaged equipment
radio equipment:
Licence No(s). of the other vehicle(s) involved in the accident

File reference used by Public Prosecutor's Office
11. In the event of damage to Name and full address of the persons who caused the accident
traffic signals:

Licence No(s). of the car(s) involved in the accident

Third Party Liability Insurer of the person(s) who caused the accident

12. How will the damaged items
be repaired, by whom and
where?
Please indicate estimated
Repair period.
13. What are the estimated
repair costs?2

14. In the event of third parties Who was to blame for the loss? (If possible, please give the full address of witnesses).
having caused the loss:

15. Who is authorized to receive Bank
the indemnity?

Account No.

2 Please enclose copy(copies) of repair estimate(s), which should show a breakdown into material costs, labour charges - including man-hours worked - and freight charges.

The undersigned insured declares that he has answered the above questions conscientiously and truthfully.

Issued at this day of

Signature