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

CLAIM FORM FOR PLATE GLASS INSURANCE
Policy No:__________
Claim No.__________
1. Name of the Insured
2. Address
3. Address where glass is situated (Please
State the precise position of the glass)
4. Size of the Plate broken
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
by the Insured.
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 ought to be made
acquainted.
Date:
Place:
Signature of Insured
Issuing
Office