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

CLAIM FORM FOR PLATE GLASS INSURANCE
The issue of this form is not to be taken as an admission of liability

                         Policy No.____________________
                        Period:_______________________
                                               Claim No.:_____________________ 

1.	Name of the Insured:	
2.	Address:	

3.	Address where glass situated (Please state the precise position of the glass)	

4.	Size of the plate broken:	
5.	Cause of Breakage:	

6.	Date of Breakage:	
7.	Name and address of the person causing breakage:	

8.	Was he in any way employed by the Insured?	
I hereby declare that the foregoing statements are made by myself and are true in all respects and that I have not attempted to conceal from the Company anything with which it ought to be made acquainted.

Date :                                 Place :                                                  ________________________ 
                                                                                                    Signature of the Insured / Claimant
WitnessLign.) :______________________
Name :
Address :

ROUGH SKETCH OF BREAKAGE

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