UNITED INDIA INSURANCE COMPANY LIMITED
(Regd. & Head Office: 24 Whites Road, Chennai-600 014)
INDUSTRIAL ALL RISKS POLICY
CLAIM FORM

POLICY NO. CLAIM NO.
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1. (a) Name
(b) Address for correspondence
(c) Name of Mortgagee or other persons
having interest in the property
(d) Location of the loss
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2. DETAILS OF INSURANCE
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Name of Insurer Policy No.(s) Sum Insured Period
Rs. From To
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N.B: If insurance is effected with other companies copies of each such policies to be attached
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3. DETAILS OF LOSS
4.
(a) Time and date of Fire/loss
(b) Cause of fire/loss
(c) Item of policy affected
(give description)
(d) Occupation of the premises
at the time of fire/loss
(e) Has the fire/ loss been reported
to fire brigade
(f) Has the fire/ loss been reported
to police
4. Extent of loss (
Give full details)
The undersigned policy-holder declares to have answered the above questions conscientiously and
truthfully and are liable and fully responsible for the correctness and completeness of his statement.
Place:
Date: Signature
(The issue of this form does not constitute admission of liability)