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United India Insurance Claim Form

The document is an 'All Risks' claim form from United India Insurance Company Limited, requiring the claimant to provide personal details, circumstances of the loss or damage, and information about any other insurance. It includes specific questions regarding the missing property, police notification, and previous claims. The form emphasizes that its issuance does not imply admission of liability by the insurance company.

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mayurgujrati00
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32 views2 pages

United India Insurance Claim Form

The document is an 'All Risks' claim form from United India Insurance Company Limited, requiring the claimant to provide personal details, circumstances of the loss or damage, and information about any other insurance. It includes specific questions regarding the missing property, police notification, and previous claims. The form emphasizes that its issuance does not imply admission of liability by the insurance company.

Uploaded by

mayurgujrati00
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

UNITED INDIA INSURANCE COMPANY LIMITED

REGD & HEAD OFFICE NO 24 WHITES ROAD CHENNAI – 600 014

“ALL RISKS” CLAIM FORM


THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
QUESTIONS TO BE ANSWERED BY THE CLAIMANT
POLICY NO.
CLAIM NO.

1. Name of Insured (in full)


2. Address
3. Occupation
4 When & where did you last see the missing
. property
5 On what day and at what hour did you first
. discover the loss or damages ?
6 State (full particulars must be given) the
. circumstances of the loss or damage

7 If claim is in respect of jewellery, when was


. the property last overhauled by a jeweler?
Give name & address of firm
8 Have you informed the Police Authorities? If
. so, when and where?
9 Are you the sole owner of the property
. damaged or stolen?
1 Are there any other insurance upon the same
0 property? If so, give full particulars.
.
1 Have you ever before sustained loss of the
1 same nature? If so, give particulars.
.
I/We the above named do declare and set forth that at or about_____________________o’clock
on the ________________________, the articles enumerated overleaf, and more particularly
described in the list lodged with the Company, were____________ and I/We do further declare
that no other person than myself / ourselves has/have an interest in the said property by Bill of
Sale, or as Owner, Mortgage Trustee, or otherwise, and that there is no further insurance except
as above mentioned, in this Company or any other company, whereof we claim the sum of
Rs._______________.
Witness my / our hand this_____________ day of ______________ 200 ____.
Signature of Insured________________
Witness (Sign.)
Name
Address

ALL RISKS CLAIM FORM


FULL NAME & DATE OF PRICE DEDUCTION SUM ITEM NO. IN REMARKS
DESCRIPTION ADDRESS OF PURCHASE OR PAID FOR AGE, CLAIMED THE LIST
OF STOLEN PARTY FROM PRESENTATION USE FOR ATTACHED
ARTICLE WHOM AND/OR PRESENT TO THE
ARTICLE WEAR & VALUE POLICY
PURCHASED TEAR
OR BY WHOM
PRESENTED

Signature of Insured________________

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