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

NEON SIGN CLAIM FORM

1. Name of the Insured
2. Address
3. Policy Number
4. Period of Insurance From_____________to____________
5. Date of Installation of damage
Sign Board and Amount
6. State when the accident occurred
7. How did it occurred
8. Whether total loss/Partial loss:
9. Estimated amount required
10. Name and Address of witness to accident
11. Name and address of repairer
12. Amount claimed
DECLARATION
I hereby declare that the foregoing statements are made by myself and are true in all respect and that I
have not attempted to conceal from the Company anything with which it out to made acquainted.
Date:
Place:
Signature of Insured
Issuing
Office