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

                            Fire Insurance Claim Form

1.	Name and Address of Insured:

2.	Please give following details pertaining to all the policies involved in fire accident: 

Policy             Risk             Location        Sum Insured        Estimated 
          Number          Covered     					    amount of loss

     (i)
     
     (ii)
   
     (iii)      

3.	Period of Insurance:

4.	Date and Time of Loss:

5.	Nature and Cause of Loss 
(Please describe the circumstances
 leading to the loss)
      
6.	Give details of insurance with any                          				                            
          other insurance company on the risk							involved in fire/accident
      
7.	If insured is not sole owner, the nature of his/their			  interest in the property and details of other interests

8.	Whether loss intimated to 
(1)	Police
(2)	Fire Brigade     
                           						
9.	(i) Was any claim reported in the past on the 				
        same property during current policy period.
  (ii) If so, give details regarding:
(a)	Cause 
(b)	Date of incident
(c)	Claim 
(d)	Policy Issuing Office
(e)	Amount of claim paid/Outstanding Rs.

   I hereby declare that the particulars furnished above are true and correct to the best of my knowledge.

PLACE:

DATE:                                                  Signature of Insured

To be filled in by Dev. Officer/Br./D.O.

Fire Claim No. _____________________________

Branch/ 
D.O. 
Code NO.	R.O.
Code No.	Dev.
Officer’s 
Code No.	Agency 
Code No.	Premium Payment Particulars	
				Receipt No BG/ CD No	Date of
Payment	Amount Rs.