UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO. 24 WHITES RD, CHENNAI -600 014

PLATE GLASS INSURANCE - CLAIM FORM
(The issue of this form does not constitute admission of liability.Please return this form within fourteen days of the loss together with all enclosures)

Policy No. Claim No.
1. a) Name of Insured (in full)
b) Address
c) Address of premises where breakage occurred
a)
b)
c)
2. Date and time of breakage
3. Cause of breakage
4. If caused by a person NOT in the Insured’s service state name and full
address of the person
5. Name and address of witness, if any
6. Is the Insured claiming as tenant or owner?
7. Is the premises where breakage occurred at present occupied?
8. Have instructions been given for replacement?
If noti)
Is immediate replacement required?
Or
ii) Would the Insured prefer to give an undertaking to effect
replacement when convenient to him?
i)
ii)
9. Is there any other insurance against the present loss under any other
policy? If so, give full particulars.
10. PARTICULARS OF BREAKAGE:
No. of squares
or panes
Description of
Glass and
where fixed
Size of each Square or
Pane in Cms.
Whether
cracked or
broken out
Cost of broken items
requiring replacements
Height Width Rs.
UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO. 24 WHITES RD, CHENNAI -600 014
I /We hereby declare that the foregoing particulars are true and correct in every respect.
Place:
Date :
Signature of Insured