FIRE CLAIM FORM
Click to view procedures for lodging claim
  Policy No :
  Claim No : ( for official purpose only)
1. INSURED :    
a. Name :  
Phone:
Email:
b. Address :  
c. Name of Mortgagees or other
persons having an interest in the property : 		 
       
2. DETAILS OF INSURANCE :    
  Sum Insured (Rs) :  
  Period :  
From :
To :
       
N.B. if insurance is effected with other Companies, copies of such policies to be submitted to the company.
       
3. DETAILS OF LOSS :    
a. Time & Date of Loss.  
b. Causes of Loss  
c. Item of Policy affected
(give description ). 		 
d. Occupation of the premises at the time of Loss.  
e. Has the Fire/Loss been
reported to fire Brigade/Police ? 		 
       
4. Approximate Extent of Loss in Rs  
       
  We hereby declare that the statements made by us in the claim from are true to the best of our knowledge and belief and that we have not withheld any material information which has a bearing upon the claim.
 
Place:
Date :
 
 
 
   
  SUBMISSION OF THIS FORM DOES NOT BIND COMPANY FOR LIABILITY
 
 
 
 
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