The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

LIVESTOCK CLAIM FORM

(The issue of this form is not to be taken as an admission of liabilities)

SERIAL NUMBER .......................... PERTAINING TO SCHEME ANIMALS ONLY

A) NAME OF BORROWER: ___________________________________________

Bank's Name & Address: _______________________________________________

To,
THE NEW INDIA ASSURANCE CO. LTD.
D.O./BRANCH

Sir,

Sub: Livestock Claim Intimation.

Policy No..................... Date from.............. to ......................(period) S. Nos.................
belonging to Shri/Smt.......................................................................of ...................... died on.........................................or suffering from Permanent Total Disablement.

Kind of animal/breed Sex Tag No./Kattoo No. Natural identification marks

This paper is submitted fulfilling all formalities of above claim, please make necessary arrangements for the settlement of claim. The tags of the above animals are submitted herewith.

Thanking you,

Date:

* Strike out the portion not applicable Signature of borrower/Bank

B) DEATH CERTIFICATE OR DEATH CERTIFICATE

a) Species............ we certify that the animal described below belonging to Shri/Smt...................of ..............
b) Breed................ village.......................District................died.
c) Sex..................... Animal physically verified by me/us at the
d) Age.................... place of accident/death.
e) Tag No............/ Tattoo No.........
f) Natural identification mark:

I hereby certify that the above mentioned DESCRIPTION OF ANIMAL
animal belonging to Shri/Smt....................
..................of village...............died on .......... Breed Male/ Colour & other natural Tag Age
.......... due to accident/disease as confirmed by animal Female identification Marks No.
Post-Mortem &/or symptoms prior to death and
Observation of carcass.

Date: Signature of Vet. Doctor
Signature Signature
Name: (Seal of Office) (Seal of Office)

Qualification: Note: - Above signatories should be any two of the below mentioned authorities:
Registration No. 1) Village Sarpanch 2) Officer of Milk
Address: Collecting Centre / Govt. VAS 3) supervisor /inspector of Central Co. op. Bank 4) President or any other officer of Co. op. Credit Society. 5) D.R.D.A. or
Authorised nominee

c) BANK’S CERTIFICATE

We hereby certify that animal ____________________ bearing Tag. No. ____________ belonging to Shri/Smt.______________________ of village ____________ under DRDA __________________ in _________________ Block was insured under Master Policy No. ________________ Shri/Smt. _________________ is an IRDP beneficiary with Bank Loan A/C. No. _____________

Signature of Bank Official
Designation:
Date: Name:
Place: Address:

OFFICE NOTE
Master Policy No. _________________ period date from _______________ to ___________ Insurance Certificate No. ______________ period from _____________ to Animal died on _______________ intimated on _______________ Claim amount Rs. ___________ Insured amount Rs. _____________ Premium @ ____________ %Rs. _____________ received full/short Rs. ________________ vide receipt No. _______________ dated ___________.

THE CLAIM AND ABOVE FINDINGS HAVE BEEN FOUND CORRECT. HENCE CLAIM IS APPROVED FOR Rs. _____________________

Date on which voucher sent:
Received voucher back on:
Date on which cheque sent: Authorised Signature