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All Risk Insurance Claim Form

This document is an All Risk Insurance Claim Form that requires the insured to provide detailed information regarding their claim, including personal details, date of loss, items affected, and a description of the loss. It emphasizes that the issuance of the form does not imply liability and requests supporting documents such as a police report and correspondence with any involved authorities. The form must be completed fully and signed by the insured.

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NAVEEN KUMAR
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8 views1 page

All Risk Insurance Claim Form

This document is an All Risk Insurance Claim Form that requires the insured to provide detailed information regarding their claim, including personal details, date of loss, items affected, and a description of the loss. It emphasizes that the issuance of the form does not imply liability and requests supporting documents such as a police report and correspondence with any involved authorities. The form must be completed fully and signed by the insured.

Uploaded by

NAVEEN KUMAR
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

ADDRESS OF ISSUING ITGI/TPP/07

OFFICE

ALL RISK INSURANCE CLAIM FORM

Claim No. …………………


Policy No. …………………
Period of Insurance From …………………. To ………………………

The issuance of this form is not to be taken as an admission of liability


Please answer all questions fully.

Insured Name ……………………………………..


Address for correspondence ……………………………………..
………………………….………….
Telephone No. ……………………………………..
Date of loss ……………………………………..

Item/s affected by loss: ……………………………………..

Brief Description of loss: ……………………………………..

Cause of loss: ……………………………………..

Has the matter been reported to the Police ……………………………………..

Name of the Police Station ……………………………………..

FIR No. and date ( Please enclose original or certified copy of FIR) ……………………………………..

Name of the Carrier/Authority in whose custody the loss has taken place ……………………………………..
(if applicable)
Has the claim been lodged on the Carrier/Authority ……………………………………..

Date when the claim has been lodged on the Carrier/Authority


(Please enclose copies of the correspondence exchanged with them) ……………………………………..

Estimate of loss (with complete breakup) ……………………………………..

Any other information which you would like to provide ……………………………………..

Date ………………….. Signature of the Insured

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