Claim Form For Money-In-Transit Policy

Company Name(s): 

The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

MONEY-IN-TRANSIT CLAIM FORM
(The Issue of this form is not to be taken as an admission of Liability)
(Questions to be answered by the Claimant)
1 Name of the Insured in full
2 Address
3 Occupation
4 When the loss discovered?
5 What were the places between
which money was in transit?
6 When and where did the loss occur?
7 In whose custody was the
Money at the time of loss?
8 How was the money being carried?
i.e. whether in bags, trunks etc.
and in how many of them
9 What means of transport was
being used by the persons
conveying the money?
10 Were the persons conveying
the money accompanied by
an armed Guard? If not, state what
protection, if any was provided
11 Where the persons conveying the
Money covered under a Fidelity
Guarantee Policy or Policies?
If so for what sum/s and with which office/s
12 Give (full particulars must be given)
the circumstances of the loss or damage
13 What was the amount or the
Money being carried?
14 What is the amount of loss?
15 Have you informed the police
Authorities? If so, when and where?
16 What steps have been taken to recover
The lost money?
17 Are there any other insurances
Upon the same money? If so, give full particulars
18 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 agree that if I/we have made, or in any further
declaration the 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 henceforth be null and void.
Dated:
Witness: Signature
Issuing
Office