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

Marine Claim  Form

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

Polic No. ____________	Claim No. ___________

E R E C T I O N     I N S U R A N C E

Notification of Physical Loss or Damage.

Name	

Address	

	Question	Answer	
1.	When did the loss or damage occur?
(state date and hour)		
2.	State the site where the damage occurred and name and nearest Railway Station.		
3.	Give the details of the damage :-
(a)	to Erection Property
(b)	to property belonging to third parties	
(a)
(b)	
4.	What was the cause of the damage?
(e.g. Defective materials, faulty design, giving particulars of parts concerned).		
5.	Is any one responsible for the damage ?
Is there any Possibility of recovery ?		

	Questions	Answers	
6.	How will the damage be repaired ?
Please state in detail whether any parts must be replaced;  (Give weight and value of damaged parts.)
		
7.	What is the estimated amount of the loss or damage ?	Rs. 	
8.	How did the damage occur ?		

(This question must be answered in detail giving a sketch, wherever possible and supported by statements of witnesses)

9.	Do you wish to carry out repairs yourself ?
Do you wish to entrust repairs to another Firm (State name).		

       As soon as a loss or damage has become know, the Company at its Head Office must be notified without delay, on the present form.  The Agents are not authorized to accept Notification of Loss or Damage.

     The undersigned Policy - holder declares to have answered the above    questions conscientiously   and truthfully and he is liable for the correctness and completeness of his statements.

	___________________
	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