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

                                  JEWELLER’S BLOCK CLAIM FORM

POLICY NO. _____________________	CLAIM NO._______________________

1)	Name & Address of the Insured (In full)	:

2)	When were the diamonds at the time of 
the loss?	:

3)	For what purpose were they there?	:

4)	When and where the missing diamonds
	were last seen and by whom?	:
	OF JULIE DIAMOND ON 3.12.1992.

5)	On what day and what hour and how
did you first discover the loss?	:

5)	Give full particulars of the circumstances
of the loss.	:

5)	At which police Station the loss has
been reported (Please attach a copy
of give full details of the report made)	:

5)	Are you the sole Owner of the lost
Diamonds? If not, state your exact
Interest and that of any other person
or persons, if any	:

5)	Is these any other Insurance on the 
diamonds? It so, give full particulars	:

5)	Have you ever sustained any loss of the
	same before	:

11)	What was the value of each Diamonds?	:

12)	When were the diamonds purchased and
From whom (a copy of the Invoice
Bill should be attached)	:

13)	Any other Remarks	:

_______________________
INSURED’S SIGNATURE

DATE :___________

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