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

STUDENT SAFETY INSURANCE CLAIM FORM

The issue of this form is not to be taken as an admission of liability
Policy No. ________________ Claim No.________________

Branch/Unit. _____________

(To be completed by the Insured)

1. (a) Name of the Insured (in Full): _____________________________________

(b) Address in full: _________________________________________________

(c) Name of the Insured Student: _____________________________________

(d) Age of the Student: ______________________________________________

2. (a) Date of accident: ________________________________________________

(b) Time of accident: ________________________________________________

(c) Where it happened: ______________________________________________

(d) Name and address of witness: _____________________________________

3. How did the accident occur? __________________________________________

4. Nature of injury received: _____________________________________________
(If to limb or eye state whether right or left)

5. (a) Nature of disablement: ____________________________________________

(b) Extent of disablement: ____________________________________________

(c) Present state of incapacity: _________________________________________
(If admitted in hospital please state the name of hospital and period of treatment)

6. Details of medical expenses incurred supported: ____________________________
By medical bill and reports etc.

7. Name and address of attending physician: ___________________________________

8. (a) Where and when can a medical officer of the: _____________________________
company visit you if necessary

(b) Name of nearest railway station and: ____________________________________
distance therefrom

We hereby declare that the foregoing statements are made by ourselves and true in all respect and that we have not attempted to conceal from the company anything with which it ought to be made acquainted.

Signature of Head of the Institute
Date: