THE ORIENTAL INSURANCE COMPANY LIMITED
10th Floor Hansalaya, Barakhamba Road, New Delhi

CLAIM FORM
(The issue of this form is not to be taken as an admission of liability)
WITHOUT PREJUDICE
The Divisional /Branch In -charge CLAIM NO. _________________
The Oriental Insurance Co.Ltd. POLICY ____________________
___________________________ PERIOD: FROM_____TO_____
___________________________ DATE OF LOSS:___________
Dear Sir,
RE: CLAIM UNDER SWEET HOME INSURANCE POLICY NO. __________
I furnish hereunder the details of claim in respect of myself/spouse/my household article ____________________ covered
under Sweet Home Policy for your necessary action.
1. Name of Insured/claimant : ______________________
2. Details of Bank Account : S. B. Account No._____________
_________________ Bank
3. Residential address : __________________________
__________________________
4. Telephone No. : __________________________
5. Other co-existing identical insurance, if any, : __________________________
details thereof. __________________________
6. Previous claim, if any, details thereof : __________________________
7. Details of current claim:
I/We declare that foregoing statement are true to the best of my/our knowledge and belief , that the articles and property
described hereinabove were damaged/stolen/injuries/death to self/spouse under the circumstance above described and that
such articles and property belong to the persons named, and no other persons having any interest therein whether as owner/
Mortgagee/Trustee or other wise. I/We further declare that if I/we have made, or in any further declaration the Company
may require in respect of the said accident, shall make any false or fraudulent statement and or suppression and or
concealment , my /our claim shall absolutely forfeited and the policy in question shall be null and void.
Signature of the Insured/Claimant
Date: Place:
Encls: 1. 2 . 3. 4.
* To furnish the required document depending upon the type of claim.
**In case the space provided for in the format is insufficient kindly mention overleaf..
Sr.
No.
Section Date of
occurrence
of loss
Cause of
Loss /
Accident **
Brief
description
of loss**
Details of
articles
damaged/
stolen
Sum
insured
of the article
damaged/
lost.
Details of
FIR/Fire
Brigade report
Doctors report/
post-mortem
report*
1. I -Fire
(Building)
2. II- Fire
(contents)
3. III- Burglary
4. IV -
Breakdown
of household
gadgets
5. V - PA