THE NEW INDIA ASSURANCE COMPANY LIMITED

Registered & Head Office- 87, M.G. Road, Fort, Mumbai-400001.

BAGGAGE INSURANCE CLAIM FORM

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

QUESTIONS TO BE ANSWERED BY THE CLAIMANT

POLICY NO: 610410/48/09/03/00000276

CLAIM NO.

Name of the Insured ABHISHEK GUPTA Name of the Beneficiary ABHISHEK GUPTA Address of the beneficiary 309 UNIVERSITY PARK, ROCHESTER, NY-14620 Traveled from DEL Traveled to JFK

M/s Secure Wrap India (P) Ltd; Hyderabad.

Name of the Airlines and its # AEROFLOT SU233/SU100 SECUREWRAP receipt, Showing Bag Tag and receipt number DELG3R30/DELF3R52 Airline Ticket # PIR issued by which airlines Passport # F5035210 PARTICULARS OF BAGGAGE LOST OR DAMAGED FULL DESCRIPTION OF BAGGAGE LOST OR DAMAGED DURING TRAVEL VALUE OF ITEM LOST AND DAMAGED SUM CLAIMED FOR PRESENT VALUE REMARKS

I/We the above named do declare and set forth that at or about_9:20PM____________oclock on the __Jan 3RD 2013______________________, the Wrapped baggage enumerated as above, and more particularly described in the list lodged with the Airways, were enclosed and I/We do further declare that no other article were damaged or lost except as above mentioned, whereof we claim the sum of Rs.21000_______________. Witness my / our hand this_3rd__________________ day of ___Jan______________ 2013 _.

Signature of Beneficiary ABHISHEK GUPTA_______________________________________________________ Phone # _302-353-2860___________e-mail ID abhishek.g82@gmail.com___________