UNITED INDIA INSURANCE COMPANY LIMITED
Head Office: 24, WHITES ROAD, CHENNAI - 600014

FIRE INSURANCE CLAIM FORM

1. Name and Address of Insured:
2. Please give following details pertaining to all the policies involved in fire accident:
Policy Number Risk covered Location Sum Insured Estimated amount of loss
(i)
(ii)
(iii)
3. Period of Insurance:
4. Date and Time of Loss:
5. Nature and Cause of Loss
(Please describe the circumstances
leading to the loss)
6. Give details of insurance with any other insurance company on the risk involved in fire/accident
7. If insured is not sole owner, the nature of his/their interest in the property and details of other
interests
8. Whether loss intimated to
(1) Police
(2) Fire Brigade
9. (i) Was any claim reported in the past on the
same property during current policy period.
(ii) If so, give details regarding:
(a) Cause
(b) Date of incident
(c) Claim
(d) Policy Issuing Office
(e) Amount of claim paid/Outstanding Rs.
I hereby declare that the particulars furnished above are true and correct to the best of my knowledge.
PLACE:
DATE: Signature of Insured