The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

Claim Form For Neon Sign/Glow Sign

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

Policy No.:.........................................
Claim No.:.........................................

1. Name of the Insured:

2. Address:

3. Address where the glass situated
(Please state position of Neon Sign)

4. Size of Neon Sign

5. Cause of Breakage

6. Date of Breakage

7. Name and address of the
person causing breakage

8. Was he in any way employed
by the Insured

9. The make and Origin of the Neon Sign

10. Cost of Neon Sign (Paid)

11. Additional observations, if any:

I/We hereby declare that the foregoing statements are made by myself/ourselves and are true in all respects and that I/We have not attempted to cancel from the Company anything which it ought to be made acquainted.

Signature of the Claimant

Date:

N.B. Please give a rough sketch of the breakage on the reverse.