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

Policy No. __________	Claim No. ___________

Notification of Loss or Damage for Contractor's All Risk Insurance

Claim No.
Title of contract insured :
Name(s) and address(es) of Insured(s).
Location and address of Contract Site:
Name of Supervising Engineer
Nearest Railway Station (Airport)
Advisable approach route to contract Site from railway station (airport) or otherwise		
1	Which items were damaged ?
(a)	Contract works
(b)	Construction plant and equipment
(c)	Construction machinery		
2	When did the loss or damage occur?
(State date and exact time)		
3	How did the damage occur and what was its probable cause ?
(Attach sketches, photos etc.)		

		

4	How far had construction of the damaged item (s) progressed at the time of the occurrence of damage?		
5	Give name and address of witness to the occurrence :		
6	How will the damaged items be repaired.		
7.	Will any alterations or improvements be made to design, construction or material when repairs are carried out ?		
8.	What are the estimated costs for the repairs of damage to
(a)	Contract Works?
(b)	Construction plant and equipment ?
(c)	Construction machinery?		
9	Is Third Party Liability involved ?		
10.	Are existing buildings or surrounding property damaged ?		
11	Remarks

	

The undersigned Insured declares to have answered the above questions conscientiously and truthfully.

Dated ________________ this _____________________ day of ________________________20_________

Signature ________________________________________________________________________________

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