The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

CLAIM FORM FOR TELEVISION/VCR/VCP INSURANCE
Claim No.____________ Policy No._____________
This form is issued without admission of liability and must be completed and returned to the Company
immediately.
1. Name and address
2. a) Particular of the set Television
b) Cost Price
c) Date of Manufacture
d) Date of Purchase
VCR VCP
3. Date of loss or damage The purpose for which
the set was being used Private:
Commercial
4. Address at which loss or damage occurred:
5. a) Cause of loss or damage (in detail):
b) I. If by Theft
i) Time of Day:
ii) How committed:
iii) By whom discovered and when:
iv) Have police been notified, if so when:
v) Give address of Police Station
II. If the aerial or installation is damaged:
i) Date and time when it happened
ii) By whom discovered and when:
iii) Has any estimate been obtained for repairs/replacement(s) if so, from
whom? Please attach estimate.
III. If by Fire
i) date and time when it happened:
ii) by whom noticed and when:
iii) how did the fire start?
iv) Has estimate for repairs been obtained? If so, please attach estimate
v)
6. Are you insured against the present loss under any other policy?
I/we hereby declare that the foregoing statements are true to the best of my/our knowledge and
belief, and that such property belongs to the undersigned and no other person is having any interest herein
whether as owner , Mortgagee Trustee or otherwise
Insured Signature
Issuing
Office