The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-4000

MONEY INSURANCE CLAIM FORM
ANSWER ALL QUESTIONS AND FULLY

Policy No. C.T. _____________D. O. / Unit _______________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 ____________________