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

Shopkeeper’s Insurance Claim Form

1. Name and Address of Insured :

2. Please give following details pertaining to all the Policies involved in fire accident :

Policy Risk Location Sum Estimated
Number Covered Insured amount of loss
Rs. Rs. Rs.

(i)

(ii)

(iii)

3. Period of Insurance

4. Date and Time of Loss

5. Nature and Cause of Loss (Please describe the
circumstances leading to the loss)

6. Give details of Insurance with any other insurance
Company on the risk involved in fire/accident

7. If insured is not sole owner, the nature of his/their
Interest in the property and details of other interests

8. Whether Loss intimated to

(i) Police

(ii) Fire Brigade

9. (i) Was any claim reported in the past on the same
property during current policy period

(ii) If so, give details reg :

(a) Cause

(b) Date of incident

(c) Claim Number

(d) Policy Issuing Office

(e) Amount of claim paid / Outstanding Rs.

I hereby declare that the particulars furnished above are true and correct to the best of my knowledge.

PLACE-

DATE-

To be filled in by Dev. Officer / Br. / D. O.

Fire Claim No. _______________

Branch
D. O.
Code No. R. O.
Code No. Dev.
Office's
Code No. Agency
Code No. Premium Payment Particulars