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

RAJRAJESWARI MAHILA KALYAN CLAIM FORM

The issue of this form is not to be taken as an Admission of liability.
CLAIM NO._____________________________________________

SECTION I (TO BE FILLED IN FOR ALL CLAIMS)

1. (a) Insured’s Name __________________________________

(b) Address: ____________________________________
____________________________________
____________________________________
____________________________________

(C) Age: ____________________________________

(d) Marital status: _____________________________________

(e) Name of Husband (if married): __________________________

(f) Occupation of husband: ________________________________

(g) His Age: ___________________________________________

(h) If not married, name of the nominee: ____________________

(i) Age of the nominee: __________________________________

(j) Relationship with Insured: ______________________________

2. (a) Policy No. ________________________________________
(b) Period From ________________to ____________________
(c) Issued at _________________________________________

3. (a) Name of deceased/injured : ____________________________
(b) Particulars of Accident: ______________________________
(c) Date and time of Accident: ____________________________
(d) Place of Accident: __________________________________
(e) If removed to hospital, name of the hospital: _________________
_____________________________________________________

4. Do you have any other RMK policy? Yes/ No
(a) If yes, Name of the company: _________________
(b) Policy No.: ________________________________
(c) Period ____ yrs From __________ to _____________
(d) Issued at: ______________________________

5. Claim in case of Divorce proceedings
(a) Legal proceedings initiated by: _________________________
(b) Name of the court: __________________________________
(c) Date of filing the case: _______________________________
(d) Date of decree: ____________________________________
(enclose certified copy of decree)
(e) Name of Advocate and his address: ______________________
(f) Legal expenses incurred: _______________________________
(enclose Documentary evidence)

6. Details of Loss/Damage of household goods/personal effects
(a) Date of accident: _____________________________________
(b) Cause of loss/damage: _________________________________
(c) In case of burglary/theft, whether FIR has been lodged: ________
(d) Items lost/damaged Amount. Rs.
1. ____________________ ______________________
2. ____________________ ______________________
3. ____________________ ______________________
4. ____________________ ______________________
(e) Are you the sole owner of the property lost/damaged: __________

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 witness ____________ (Signature of the Claimant)

SECTION II (TO BE FILLED IN BY HOSPITAL AUTHORITIES)

1. Name and address of the hospital: __________________________________
______________________________________________________________

2. Date of admission: ______________________________________________
3. Date of death: _________________________________________________
4. Cause of death: ________________________________________________
5. Extent of injuries: ______________________________________________
6. Date of postmortem: ____________________________________________

Date ____________
Rubber Stamp of Hospital Signature of the Competent Authority