THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd & Head Office : New India Assurance Building,
87, Mahatma Gandhi Road, Bombay – 400 001

The Issue of this form is not to be taken as an admission of liability

Policy No. Claim No._______________

MACHINERY INSURANCE
Notification of Physical Loss or Damage

Name
Address

Question Answers

1. When did the loss or damage occur ?
(State date and hour)

2. Give the name and address of the witness
to the occurrence.

3. What was damaged ?
(a) Item of the Inventory (a)

(b) Sum Insured (b)

(c) Type of machine output of capacity (c)

(d) Manufacturers and year of manufacture (d)
(Full details on maker's plate to be
given)

(e) What is the cost of replacement of the (e)
machine by a new machine of the same
size and capacity.

4. (a) Was the property brand new or second (a)
hand ?

(b) What was the last occasion before the (b)
damage when the machine was over-
hauled or attended to for maintenance
or damage

5. Is the damaged property totally destroyed ?

Questions Answers
6 What has occurred and which parts of the property are damaged to such an extend the replacement is necessary?

7 Has the period of guarantee expired?
If so, when ?

8 What is the estimated amount of loss or
Damage?

9 What was the cause of the damage and how did it occur?
(This question must be answered in detail and a sketch given wherever possible)

10 (a) Has the property undergone any repairs
previously
(b) What was the nature of such repairs ? (a)

(b)

11 Give the name and address of the workshop where repairs will be executed :
(Provisional repairs will be indemnified)

As soon as loss or damage has become known the Company at its Head Office must be notified without delay on the present form. The Agents are not authorized to accept notification of loss or damage.

The undersigned policyholder declares to have answered the above questions conscientiously and faithfully and he is liable for the correctness and completeness of his statement.

_________________ 20_____ ________________________
Signature

1. What has occurred and which parts of the
property