UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO 24 WHITES ROAD CHENNAI – 600 014

FIDELITY GUARANTEE INSURANCE - CLAIM FORM
(The issue of this form does not constitute admission of liability. Please return the form duly completed within three months of the discovery of the loss together with all the particulars annexures)

Policy No. Claim No.
1. a) Name of Insured (in full)
b) Address
c) Business
a)
b)
c)
2. a) Name of the defaulting employee in full
b) His present address
a)
b)
3. Amount of loss sustained Rs.
4. Date of discovery of the defalcation
5. Date (s) of defalcation
6. How exactly was the defalcation committed? If space is not sufficient, please
give full and detailed particulars on a separate signed sheet. (Also please attach
a certified statement containing all entries in the Insured’s books of accounts
relative to the defalcation in the order of their dates)
7. Please reply fully to the following questions regarding the duties of the
employee at the time of defalcation:-
a) In what capacity was he engaged and where? Money
b) In what way did money reach his hands?
c) What was the largest sum which he held in his hands at any one time and
for how long?
d) Was he allowed to pay out any amounts on the Insured’s behalf? If so,
details
e) Who authorised these payments or issues?
f) Was he required to give printed receipts from a book with counterfoils? If
so, how often were the counterfoils examined and checked and by whom?
g) Were moneys paid into Bank by the defaulting employee? If so, how often
were Bank Books examined and checked and by whom?
h) What balance, if any was allowed to be kept in his hand?
i) How often were the Cash Accounts balanced and how was their accuracy
checked? Please explain fully.
j) How often were accounts sent direct to Customers independently of the
employee?
Stock
k) Did the employee have charge of stock? If so, in what way did stock reach
his hands?
l) Was he allowed to issue stores or materials independently? If not, who
authorised these issues?
m) How often was the position of stock handled by the employee checked?
n) When was the last check made?
a)
b)
c) Rs.
d)
e)
f)
g)
h) Rs.
i)
j)
k)
l) m)
n)
8. How often were the Account Book/ Stock Books at the place of the defaulting
employee’s employment audited and by whom? When was the last audit done?
9. Has the Insured any moneys, estate, or effects of the employee in his
possession? If so, give particulars with amounts.
10. Does the Insured hold any other security from the employee? If so, state its
nature and amount.
11. Is the defaulting employee a member of a joint family, or does he hold any
property, furniture or other effects? If so, give details.
12. Has the employee any near relatives? If so, give their names and addresses, if
known.
13. Has the Insured taken any action against the employee? If so, state the nature of
action taken.
14. Has the loss been reported to the Police? If so, state at which Police Station and
what action, if any has been taken by them.
I / We hereby declare that the foregoing particulars are true and correct in every respect.
Place :
Date : Signature of Insured:
Witness: