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

SUHANA SAFAR POLICY (Domestic Travellers Insurance) CLAIM FORM

Insurance of this claim form does not in any way amount to admission of liability by the insurance Company. The completed Claim form should be returned to the Policy issuing office immediately.

1. Name of the Insured
2. Address:

3. Policy No.
4. Date of scheduled departure
5. Date of Schedule return
6. Date of actual departure
7. Date of actual return to the place of departure
8. Has the policy been extended beyond the original date of scheduled return?
9. If yes, please give the name and address of the office extending the cover.

Yes/No
10.Period upto which the cover was extended.
11.Section under which the present claim is being made Section I (Personal Accident)/
Section II (Baggage)
Note: If the present claim is under Section- I. Please fill in Part A below, else Part B. (If it is under both please fill A & B.)

Part A (Personal Accident)

12. Name(s) of injured person(s)

13. Nature of Injuries sustained

14. Details of accident Date:.....................Place:..................
Time:....................
15. Cause of accident (describe briefly how the accident occurred)

16. Amount of compensation claimed
Under Section-l (A)

Under Section-l (B)
17. Name (s) & Address(es) of the Doctors (s) attending to the insured since the time of accident

Note: 1. Report of the attending medical practitioner certifying interalia that cause of injuries was primarily due to the accident described above. (the percentage of disablement sustained by the insured should be certified by the doctor if it falls under sub item (iv) of the partial permanent disablement section of the schedule of compensation described in the policy).
2. If this claim is due to death of an insured person, please attach certificate, post-mortem report and or inquest report (if any) and policy report.

If the claim is only under Part A please go to “declaration” below

Part B (Baggage)

18. Nature and cause of loss

19. Discovery of loss Date ..................... Time................ Place.............. By whom discovered
20. Place and Time when the stolen property was last seen
21. Has any report been lodged with the Policy or other authorities as appropriate? If so, please attach a copy. If not, please state reasons.
22. Has any recovery been made? If so, give details.

23. Has any claim been lodged with the party responsible for the care and custody of the Baggage? If so, the amount of compensations received if any.
24. Do you have any other insurance of the Baggage lost?
If so, name and address of the Insurer and the amount of claim lodged.
25. State the value(s) of article(s) lost/damaged (attach separate sheet if necessary)
Declaration
I hereby declare that the foregoing statements are true and correct.

In respect of claim made under section II of the policy (as described in Part(B) above) I hereby understand and agree that if any of the article forming part of its claim are subsequently recovered or any other compensation is received in respect thereof, the same would be notified to you and the claim amount/compensation received in respect of the concerned articles shall be refunded.

Place:..................................

Date:.................................. Signature of Insured