The New India Assurance Company Limited 
                  Head Office: 87, M G Road, Fort, Mumbai-400001

SUNDRY HULL CLAIM FORM

ISSUANCE OF THIS FORM IS NOT BE TAKEN AS ADMISSION OF LIABILITY

I.	Name of the Insured and Address:

II.	Name of the Assignee, if any:

III.	Particulars of the Insured Vessel :

	a.	Name					b.	GRT

	c.	Registration No.			d.	Place of Registration

	e.	Classified as				f.	Construction

	g.	Year Built				h.	Engine No.

IV.	Particulars of the Tindal & Crew Members

	Tindal						Name & Address

	Tindal’s Father				Name & Address

	Crew Members				Name & Address

1.						2.

3.						4.

5.						6.

V.	Policy Particulars 
	No.					Issuing Office

	Period of Cover			Terms

	Sum Insured Rs.
VI.	Detailed particulars of the casualty giving to this claim indulging place (Anchor-bearing) Time, Date and the cause of the casualty:

VII.	Actions taken to save the vessel from imperilment:

VIII.	Actual loss / damage suffered :

IX.	Human lives lost /saved – How and by whom ?

X.	Has the casualty been reported to the authorities – Port Officer / Police / Notary Public ? If so, give particulars:

XI.	Was the vessel seaworthy in all respects before commencement of the ill fated voyage or immediately before the casualty?

XII.	(a)	When was the vessel last repaired ?

(b)	What was the repair work carried out?

XIII.	Particulars of loss minimization efforts and expenses incurred, if any:

XIV.	Estimated Loss :

	The above particulars are true to the best of my knowledge. I/We further declare that no other person has any interest in the  said properly, as Owner Mortgagee, Trustee of otherwise, and that it is not otherwise insured against  with this or any other Office, except as above stated.

	Place :

	Date :
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