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

				MONEY INSURANCE CLAIM FORM

              			 ANSWER ALL QUESTIONS AND FULLY 

Policy No. C.T. _____________D. O. / Unit _______________Claim No. ___________  

1.	Name of Insured (in full) ___________________________________________     
  
2.	Address: ________________________________________________________

___________________________________________________________________ 

3.	Occupation: ______________________________________________________  

4.	a. When was the loss discovered? (Give time & date). _____________________

          b. What were the places between which money was in transit? _______________

          c. How and where did the loss occur? __________________________________     

          d. What was the amount being carried? ________________________________ 

5.	In whose custody was the money at the time of loss? _____________________   
 
6.	Were the persons conveying the money accompanied by an armed guard? If not, state what protection if any, was provided?  ____________________________

7.	How was the money being carried? (i.e. whether in bags trunks, etc, and in how many of them)    _____________________________________________________ 

8.	 What means of transport was being used by the persons conveying the money? __________________________________________________________________  

9.	Give the circumstances of the loss or damage (full particulars must be given). ______________________________________________________________

10.	What is the amount of loss? ________________________________________     

11.	 Have you informed the policy authorities? If so when and where? _____________  

12.	What steps have been taken to recover the lost money? ______________________     

13.	Were the persons conveying the money covered under Fidelity Guarantee Policy / Policies? If so, for what sums and with which office/s? ________________________       

14.	Are there any other insurance upon the same money? If so, give full particulars. _________________________________________________________________ 

15.	Have you ever before sustained loss of the same nature? If so give particulars. _________________________________________________________________

I/We the above named, do hereby to the best of my/our knowledge and belief warrant the truth of the foregoing statements in every respect and I/We have made, or in any further declaration in company may require in respect of the said loss shall make any false or fraudulent statement or any suppression or concealment my/our claim shall be absolutely     forfeited and the Policy shall thenceforth be null and void.

Witness _______________________          Insured's Signature _____________________ 
                  (Signature)  

Name _______________________				Date:___________________
                                                                                                                                                                                          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