The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

FIRE INSURANCE CLAIM FORM
CLAIM UNDER FIRE POLICY…………………………NO…………………
1. State the day of
the week
2. State the room or
place where the
fire originated.
3. Insert description
of premises e.g.
Dwelling house,
Grocer’s Shop,
Cotton Mill etc
4 State by what
means the fire is
supposed to have
been caused
5. State the nature of
any other interest
eg. Mortgagee,
Leassee,
Purchaser on
Deposit etc.
I/We…………………………………..……………………………..…..now
residing at……………………………………..……………..holding the
above mentioned policy…………….……….in your company, do hereby
declare that on or About …………… o’clock……………….m. on
(1)……………the ……………
day of …………………………..20 a fire occurred in the
(2)……………………………………………………………………….of
The (3)…………………………………………………….situated
at………………………………………………….that the said fire was
occasioned the best of …………………..knowledge and belief by (4)
………………………………..and that the property hereinafter detailed
belonging to …. . and insured by the item…………………of the said
policy…………………………………………………………………was
destroyed or damaged to the extent of the amount as stated.
(5)……………………………………………………………………………
………………………………………………………………………………
I/we also further declare that the following is a true and complete statement of
the insurances effected on the said property:
6. Here Insert no
other Insurance
if the property is
insured only
with the
ORIENTAL if
there are other
insurance full
copies of all
policies must be
attached.
7. Where the
insurance
consists of
several items a
declaration is
required of each
value of each
item under
which the claim
is made.
STATEMENT OF INSURANCE
Amount Company Policy
THE ORIENTAL
Issuing
Office
-2-
And that the sound value of all the property referred to in the item……………….. under which the claim is
made was at time of fire (7) ………………………………………………………………………………….
……………………………………………………..
Signature of Claimant………………
Witness………………………………………………………….Date………………………20
DETAILS OF CLAIM FOR PROPERTY DESTROYED OR DAMAGED
A Fire Policy being a contract of INDEMNIY only, all claims must be based upon the actual value of the
goods at the time of the Fire no trade profit whatever being included in the claim.
Description of the Article Claimed Value at the
time of Fire
Deduction for
value of Salvage
Amount claimed i.e. actual
loss after deduction of
salvage value
TOTAL RS.