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

MARINE CLAIM FORM

The New India Assurance Co. Ltd. Place
Date

Re: Claim under Policy No.
Declaration No.
Dear Sirs,

We have to advise you of loss or damage in transit as detailed below particulars of which are stated overleaf :

1. Name and address of the consignors :

2. Name and address of the consignees :

3. Nature of goods :

4. Number and date of the Carrier's Receipt

5. Place of despatch :

6. Place of destination

7. Date of arrival of the consignment at destination
if by steamer, dates of landing and clearance :

8. Date of despatch to interior destination, if any :

9. Date of taking delivery at the final destination :

10. Reason for delay for taking delivery at final
destination, if any :

11. Date when loss or damaged noted:

12. Total number of cases and/or packages
despatched with marks if any :

13. Number taken delivery of :
2
14. Number not delivered by the Carriers (Steamer
agents or land carriers)

15. Full details of the condition of the cases and/or
Packages taken delivery of :

16. If damaged in transit, was steamer survey held
or open delivery taken ? If so, attach certificates
from the carriers :

17. Has claim been made against carriers:

18. If claim has not been lodged, state the reason
for the same :

19. Sound market value of the goods on date of arrival

20. Duty payable on sound goods :

21. Further remarks

We also enclose herewith the following documents

1) Original Insurance Policy and/ or Certificate duly
Endorsed

2) Complete invoices together with supplementaries

3) Copy of the Bill of Lading

4) Copies of correspondence exchanged with the
carriers Port Trust together with their replies in original

5) Steamers survey report

6) Carriers Certificate
(Rail, Lorry, Post and/or Air)

Address :- Yours faithfully

Signature

(*Strike out whichever not applicable)

-3- F. No. SPL - 4 (H)

DETAILS OF DAMAGES

Particulars of goods Nature of loss Estimate of repairs and/or replacements