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

CLAIM FORM FOR PLATE GLASS INSURANCE
The issue of this form is not to be taken as an admission of liability

Policy No.____________________
Period:_______________________
Claim No.:_____________________

1. Name of the Insured:
2. Address:

3. Address where glass 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 the Insured?
I hereby declare that the foregoing statements are made by myself and are true in all respects and that I have not attempted to conceal from the Company anything with which it ought to be made acquainted.

Date : Place : ________________________
Signature of the Insured / Claimant
Witness9ign.) :______________________
Name :
Address :

ROUGH SKETCH OF BREAKAGE