MATERIAL DAMAGE CLAIM FORM

In accordance with the conditions of the Policy under no circumstances should liability be admitted or any offer of settlement be made without the prior written consent of New India Assurance. This form must be completed by a person authorized to do so on behalf of the Policyholder/ Insured. All questions must be answered as fully as possible (use additional pages if necessary)

Policyholder(s) / Insured Details
Number :
Number (if known) :
Full name :*
Address :*
Contact details :
Address :
Telephone :
Work :
Home :
Mobile :
E mail :
Contact Person :
Circumstance / details for loss or damages
Date / Day / Time of loss*
Location where loss or incident occurred?*
Please explain what happened*
Is there any other insurance with any Company in relation to this loss? If so, give particulars :
If loss was caused by another person, please give their name, address and telephone number.
Have you made any other insurance claims over the last 5 years? If yes, please give details including Insurance Company name.
Details of property loss or damage
If no, supply details of other interest and party concerned.
If burglary, loss or theft or malicious damage claim. To which Police Station was it reported?
Date Reported.
Police file number.
If burglary, state means of entry to the premises.
Property Details
Descriptions of property lost or damaged (state each article/ item separately) Date Purchased & Price Present Cost of Replacement Depreciation for Age & Condition Value of Salvage (if any) Amount Claimed
 
 
 
 
 
 
 
 
 
 
 
Total
Glass Breakage
If you are the tenant of commercial premises please provide proof that you are liable under the terms of your lease. Particulars of glass damage:

Description (Plain, Plate Etc) Height Width Where fixed (window, door etc)
     
     
     
 
Name(s) and Address(es) of Person(s), if any responsible for loss or damages
If you are the tenant of commercial premises please provide proof that you are liable under the terms of your lease. Particulars of glass damage :
Name, address, and telephone numbers. Insurance Co. (if known)
Insurance Co. (if known)


 
Names, address & telephone number of witnesses of accident / loss.

Your Privacy

We collect and receive your personal information in this claim form to consider your claim. We hold it. You have rights to access it, and correct it under the Privacy Act 1993.

You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim.

We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers.

Your Declaration

I / We declare that to the best of my/our knowledge, the above are true statements of fact and that I/We have not caused the loss/damage or by any fraud or willful misrepresentation sought unjustly to benefit by the loss/damage and that the information detailed in the Schedule is a true and faithful account of the actual loss/ damage.

I/We agree to notify New India Assurance immediately if any of the lost or stolen property mentioned in this claim is subsequently recovered, and at New India Assurance’s option surrender the property to New India Assurance or refund the amount of money received by way of compensation for the property.

I/We authorize the disclosure of New India Assurance of personal information held by any other person or organization regarding or affecting this claim, and authorize New India Assurance to release to any person or organization regarding or affecting this claim.


Dated at: this: day of: Year:
Policyholder’s Signature :
Name :
Address :
Witness Signature :
Name :
Address :