Claim Form


[ Please fill in the fields marked with * asterisk ]
Please select the country/city where the form is to be submitted *  

Name of the Insured (as on the policy) *

:

Business or Occupation

:

Address

:

E-mail *

:

Tel *

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Fax

:

POLICY DETAILS :
Type of Policy :
Policy No: :
Date of Issue :
Place of Issue :
Period of Insurance     From :
Period of Insurance     To :
form1 DETAILS :
Date of Incident :
Time of Occurrence :
Place / Location of the Incident / Occurrence :
By whom discovered :
Witness Name, if any :
Full description of the incident (Including details of the property damaged - Own Property & Third Party Property) :
Estimated Amount of Loss :
OTHER PARTICULARS::
If known, state Name and Address of the person responsible for the loss / damage:
Name: :
Address :
Has the incident been reported to the Police Authorities :
If YES, Name of the Police Station :
Name/ ID of the Police Officer :
File / Reference No :
Date and Time Reported :
DECLARATION:

I / We hereby declare that the statements made above are, to the best of our knowledge and belief, are true and agree to provide any further information as may be called for from time to time in order to process my/our form1 and also declare that I/We have not made any commitment whatsoever to any Third Party
     

 

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