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

MONEY INSURANCE CLAIM FORM

ANSWER ALL QUESTIONS AND FULLY
Policy No. ____________ Claim No. ___________
1. Name of Insured (in full) ___________________________________________
2. Address: ________________________________________________________
___________________________________________________________________
3. Occupation: ______________________________________________________
4. a. When was the loss discovered? (Give time & date). _____________________
b. What were the places between which money was in transit? _______________
c. How and where did the loss occur? __________________________________
d. What was the amount being carried? ________________________________
5. In whose custody was the money at the time of loss? _____________________
6. Were the persons conveying the money accompanied by an armed guard? If not,
state what protection if any, was provided? ____________________________
7. How was the money being carried? (i.e. whether in bags trunks, etc, and in how
many of them) _____________________________________________________
8. What means of transport was being used by the persons conveying the money?
__________________________________________________________________
9. Give the circumstances of the loss or damage (full particulars must be given).
______________________________________________________________
10.What is the amount of loss? ________________________________________
11. Have you informed the policy authorities? If so when and where? _____________
12.What steps have been taken to recover the lost money? ______________________
13.Were the persons conveying the money covered under Fidelity Guarantee Policy /
Policies? If so, for what sums and with which office/s? ________________________
14.Are there any other insurance upon the same money? If so, give full particulars.
_________________________________________________________________
15.Have you ever before sustained loss of the same nature? If so give particulars.
_________________________________________________________________
I/We the above named, do hereby to the best of my/our knowledge and belief warrant the
truth of the foregoing statements in every respect and I/We have made, or in any further
declaration in company may require in respect of the said loss shall make any false or
fraudulent statement or any suppression or concealment my/our claim shall be absolutely
forfeited and the Policy shall thenceforth be null and void.
Witness _______________________ Insured's Signature _____________________
(Signature)
Name _______________________ Date:___________________
Date ____________________