THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd & Head Office : New India Assurance Building,
87, Mahatma Gandhi Road, Bombay - 400 001

POULTRY CLAIM FORM
(To be filled in by the insured)
(The issue of this form is not to be taken as an Admission of liability.)

Name of Insured (in full) ____________________________________________

Address: _________________________________________________________

Occupation: _______________________________________________________

A. Description of Bird/s claimed for:
1. Type of Bird/s and breed:
2. Colour:
3. Marks:
4. Age (in week):
5. Value prior to illness:
B. When was the bird/s first seen ill?
C. When was notice sent to Vety. Surgeon?
D. Date of attendance:
E. When first and last seen by Vety. Surgeon:
F. Name and Address of V.S who attended.
G. Place of death with date.
H. Cause of death:
If from disease, how do you account for it?
If from accident, how did it occur and name
Of the incharge during the event?
I. Which diseases are prevalent in your farm?
J. Amount of claim:
K. Is/are the bird/s insured elsewhere?
Are you receiving compensation from any other source?
If so, from whom?
L. What steps were taken by you after the disease was noticed to prevent the same?

M. When was premium paid?

I/we the above name do hereby declare to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect and I/we agree that I/we have made, or in any further declaration which the company may required in respect of the said accident, shall make any false or fraudulent statements or any suppression or concealment the policy shall be void and all rights to recover thereunder in respect of past or future accident shall be forfeited.

___________________________
Date: Signature of the Insured:

Place: Witness 1: ________________ 2: _________________