THE NEW INDIA ASSURANCE COMPANY LIMITED
                       Regd & Head Office : New India Assurance Building,
                           87, Mahatma Gandhi Road, Bombay – 400 001.

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY ANSWER ALL QUESTION FULLY
BURGLARY CLAIM FORM

1.	Name of Insured in full	
2.	Address	
3.	Occupation	

4.	a.	Full Address of Premises broker into

	b.	The day and hour the Premises
were broker into

c.	How the entrance was effected ?

c.	Which rooms were entered ?

5.	a.	Whether the premises were inhabited at
		the time of the Burglary ? 

b.	If not, for what periods have they been 
Uninhabited since the last premium
Was due

6.	a.	When did you inform the Police
		Authorities of the theft and at
		Which Police Station

7.	Whether you are the sole owner of the
	property stolen ?

8.	State the estimated value of the total
Contents of the premises at the time of
The Burglary.

1.	For what sum you insure the contents
Against Fire and with which company ?

10.	Are there any other insurance against 	Rs……………. In the………….. Insurance
	Burglary upon the same property ? If so	Company Policy No…………….
	five full particulars	Rs…………. In the ……………. Insurance
			Company Policy No………….

11.	Have you ever before sustained loss by
Fire or Burglary? If so give particulars.

    I / We above named being insured under the above Policy do hereby declare and   setforth that at or about_______________________ O' clock a.m. / p.m. on the ___________ 19 _____ a theft was committed at above described Premises in the manner stated and articles enumerated in the within list and valued at sum or Rs. _________________ were stolen therefrom and I / we further declare that no other person has any interest in the said property,  as Owner Mortgage, Trustee or otherwise, and that it is not otherwise insured against Burglary, with this or any other Office, except as above stated.

     Witness my hand this _______________ day of __________________________ 19____________

Witness	
Occupation	
Address			Signature of Insured

ECS Details of the Insured
 
1	Name of the Insured (as appearing in the Bank Account)		
2	Bank Name  		
3	Branch and address		
4	Bank Account No.		
5	Bank Account Type  		
6	IFSC Code		
7	MICR Code