The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

FIDELITY GUARANTEE CLAIM FORM
TO BE COMPLETED BY THE EMPLOYER

The issue of this form is not to be taken as an admission of liability

POLICY NO. ………………….
CLAIM NO………………………..
D.O / UNIT ……………………….
1. (a) Name of Employer in Full:
(b) Business :
(c) Address :

2 (a) Name of the Defaulting employee in full :
(b) His present address:

3. Amount of Loss sustained:
4. Date of defalcation:
5. Date of discovery of the defalcation:
6. How exactly was the defalcation committed ?
(if this space is not sufficient, please give full & detailed particulars on a separate signed sheet. Also please attach a certified statement containing all entries in your books of accounts relative to the declaration in their order of 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?
(b) In what way did moneys reach his hands?
(c) What was the largest sum which he had in his hands at any one time and for how long?
(d) Was he allowed to pay out any amounts on your behalf?
(e) Who authorized these payments?
(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) Where moneys paid into the Bank by the defaulting employee? If so, how often were the 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 his 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.
(k) Did the employee have charge of stock? If so, how often was it checked?
8. How often were the Account Books at the place of the defaulting employees employment audited and by whom?
9. Have you any moneys, estate, or effect of the employee in your possession? If so, give particulars with amounts.
10. Do you hold any other security from the Employee? If so, state its nature and amount.
11. Is the defaulter 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 address if known.
13. Have you taken any action against the employee? If so, state of what nature.
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 the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth or the foregoing statements in every respect and I/We agree that I/We have made, or in any further declaration the Company may require in respect of the said occurrence, shall make any false or fraudulent statement or any suppression or concealment my / our claim shall be absolutely forfeited, and the Policy shall henceforth be null and void.

Signature of Witness:__________________ Insured’s Signature __________________
Name : _________________________

Address: ________________________ Date:__________________

_________________________

_________________________

Date :__________________________