BURGLARY/ HOUSE BREAKING CLAIM FORM The issue of this form does not constitute admission of liability. Please return this form duly completed within Fourteen days of loss together with relevant voucher etc.. Policy No Claim No 1. a) Name   b) Address   c) Occupation 2. a) State whether property was stolen, lost or damaged b) If stolen, does insured's suspicion rest on anyone and if so, on whom ? c) When and where was Property last seen by Insured ? 3. What date/time was Theft/Loss discovered and by whom 4. State circumstances under which theft, loss or damage took place 5. Is Insured sole owner of property ? If not, give name of owner 6. If Claim is in respect of any article not separately mentioned, give number of policy item in which it is included and present value of all property to which that item applies 7. If property was stolen or lost, has complaint been made to police ? If so, attach copy thereof. If not this may be done immediately and copy thereof furnished to the Company 8. Are there other insurances on same property ? If so, give description   9. a) Has Insured previously sustained any theft or loss of or damage to property ? Yes No b) Was claim made upon any Company? If so, give name of Company, date, nature of loss and amount paid I/We hereby declare that foregoing particulars are true and correct in every respect and that property referred to is/are my/our own property. Place Date     | Motor | Fire | Marine | Peesonal Accident | Personal Accidentdeath | Hospitalization/Domiciliary treatment medical | |Burglary/House breaking | Contractor's all risks | Machinery | Erection |   Site designed and maintained by: INFOCOM Pvt. Ltd.