You are on page 1of 2

Address

for Communication

;{~9t~
(1frofi11 (fT~
ci'iftif(f

{;~~i;:tf ~,
;ft1n R'l'1l' ~ ~"'")

f\"Sf~~
1IiW~-700071

...m~:

3,

fuR'!'

$.

National

Insurance

Company

Ltd.
071

(Sublidiary 01 Gonor.1 Inluran.o Regd. <::'lIi.o: 3. MIDDLETON

CorpDration Df India) STREET. CALCUTTA700

'ALL
1. The completed claim form should

RISKS'

CLAIM

FORM
Office of the Company within 7 days

be returned

to the Issuing

of its receipt. 2. 3. A list of all lost and damaged The Company does not admit property liabilitv must be furnished hy issuing this form. in the space provided overleaf.

Name of Insured .. Address" .

Policy Claim

No. No.

Tel. No

1.

When and where last seen 7

was the

missing

property

2. or damage discovered? On what day and at what 3. State the circumstances Full particulars hour was the loss of must the loss
or

damaged.

be given.

4.

Have of the which

the

Police If

Authorities so, on what

been date

informed and No. at

loss? Police

Station

and the Dairy

5.

a)

Has a thorough ai ticles ? What steps

search

been

made

for

b)

have been taken

to

recover

the property?

6.

Is

the

Claimant

the

sale

owner

of

the

property

loss or damaged?

7.

Are there any same property?

other insurances \Jpon the If so. give full particulars.

8.

Has the claimant the same nature


7

sustained

other

losses particulars.

of

If so, give full

9.

If

claim

is

in

respect

of

jewellery,

when

-------------_. __ ._-----------~----------_._-----------------

was the property last overhauled by a Jeweller? Name and address of the Jeweller should be stated.

2.
I do articles kind, I do hereby lost affirm and declare with that the above true given statements and the statements contained in the list of of any or damaged are in all respects the particulars that and complete and are made without reservation

and in accordance further affirm effected

in the said list I claim no other trustee person

the sum of Rs ....................... myself has any interest in

and declare

to my knowledge mortgagee,

than

the said property insurances

by bill

of sale or as owner,

or otherwise,

and that

there

are no other

on the said property

by me or so far as I am aware,

by any other

person.

Date:

Sinnature

of Claimant

LIST
All claims but not depreciation must be based exceeding the upon the sums for

OF ARTICLES
actual which value

LOST

OR DAMAGED
at the insured time of the Theft, due allowance Loss or Damage, being made for

of the articles

they are respectively

and wear and tear. From wh jI j i or by V"v I I I (Receip should b I perusa tear P. Rs. Rs. claimed tion for I wear Cost received ! ! and Date or DeducpurchaAmount I sed Rs.
\

or Vouchers Jm presented attached return) for lm purchased Item No.~and I Full description I of in the articles lost or Schedule damagedI I of Policy

..

--------_._----,-----------

-...
SVP/500/7/96