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

JEWELLER’S BLOCK CLAIM FORM

POLICY NO. _____________________CLAIM NO._______________________
1) Name & Address of the Insured (In full) :
2) When were the diamonds at the time of
the loss? :
3) For what purpose were they there? :
4) When and where the missing diamonds
were last seen and by whom? :
5) On what day and what hour and how
did you first discover the loss? :
6) Give full particulars of the circumstances
of the loss. :
7) At which police Station the loss has
been reported (Please attach a copy
of give full details of the report made) :
8) Are you the sole Owner of the lost
Diamonds? If not, state your exact
Interest and that of any other person
or persons, if any :
9) Is these any other Insurance on the
diamonds? It so, give full particulars :
10) Have you ever sustained any loss of the
same before :
11) What was the value of each Diamonds? :
12)When were the diamonds purchased and
From whom (a copy of the Invoice
Bill should be attached) :
13) Any other Remarks :
_______________________
INSURED’S SIGNATURE
DATE :___________