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

GUN INSURANCE - CLAIM FORM
The issue of this form is not to be taken as an admission of liability.The completion and return of this from to the Company should not be delayed.If any of the particulars required cannot be immediately given, they may be forwarded to the
Company afterwards as soon as possible.

Address: Policy No.-------------------------------------
Claim No.
-------------------------------------
1.
a) Name of Insured:
b) Address:
c) Address for communication
a) Policy number:
b) Period of the Policy:
c) Limits of Indemnity under the Policy:
2.
Particulars of accident:
a) Date of occurrence:
b) Place of accident:
c) When did you first come to know of the accident?
d) When was the accident reported to you?
e) When was the claim first notified to the Insurer?
Date:
Time ---------
A.M./P.M
3 Type of loss
Damage to Gun:
Loss of Gun
4 Nature of loss
Fire
Burglary
Theft
Others
5 Amount of Loss
6 In case of loss By way of damage,Where can the gun be inspected
6.
Particulars of consequences of the accident:
a) Has any person sustained any injuries in the accident? If so,
i) Give name/s, address/es and occupation/s of such person/s.
ii) State where such person was at the time of accident.
iii) Have the injured persons been removed to hospital or
medically attended? If so, give particulars.
(iv) Relationship if any with the Insured Person
b) Has the accident caused damage to property or livestock? If so,
give name/s and address/es of the owner/s of the property and /
or livestock and full description of the property and state the
nature of and extent of damage.
c) Has any claim been made upon you by any person? If so, state
by whom and give full particulars (if claim has been made in
writing, attach a copy of the notification received and of the bill,
if submitted).
d) Estimated amount of claim separately under (a), (b) ,(c) and (d).
7. a) Give, if possible, the names and addresses of all witnesses to the
accident.
b) Has the accident been reported to any authority/Police? If so,
state to whom and attach a copy of the report submitted.
c) What action, if any, has been taken by the authority?
d) Give particulars of any other insurance, if any, in respect of the
same risk.
I/We, the above named, do hereby, to the best of my/our knowledge and belief, warrant
the truth of the forgoing statements in every respect; and I / We agree that if I / We have
made, or in any further declaration the Company may require in respect of the said
accident, shall make any false or fraudulent statement, or any suppression or
concealment, my / our claim shall be absolutely forfeited, and the Policy shall be null and
void.
Insured’s Signature
Date