3. ~$, ~-700 071 RegisteredOffice: 3, Middleton Street, Calcutta-lOO001.

BURGLARY CLAIM FORM'

•• .1;\1; I.
'1,lf' ~ CLAIM NO. _

'Nariie of'lnsured __ ----'--- _ Policy No. _

j f~i f1~ ' •
, ~(J(Jress: '

Telephone No. _
l:l~ I _ •.__ - '.. --'~- .-
1. Address of premises where loss occured (State
whether private house, godown, sale-shop,*fl'ilt
hotel, etc. outbuilding thereof) ,

'''{QIi)t.N8~.~e~~
(R~i1way S~mion.
2.; If the premises were forcibly entered,
(a) at what date and hour was the Theft
.;, !HI!;;" committed 7, ~
LJo' :".i> I, I:' .
(b) how precisely vyas entrance effected 7
I'
"
-------------.---------.--.-----
3. If the premises were not forcibly entered.
(a) from what part of the premises was the
property t aken 7

(b) . at whet date end hour (if known) was the

Theft committed? If not known, when' was
the stolen property last seen prior to the
Theft ? -----------_._---~- ------------
has
Have
where
Has
(a)
(a)
do
(c) the
If so,
not,the
on
any
you thief
the what
upon
arrest
suspectbeen
Police
premises
day
what
been identified
Authorities
and
inhabited
date
,anyone? and
made? 7not.
been
at Ifwhich
at atwhatinformed
thewhat
Police
time
hour of
ce is there that a Theft has
the the
of
werebeen
Theft
actually
Station Theft?
they ?last
the inhabited
committed?
and Dairy No.prior
? to the Theft?
4. (d)
5. (b)
(b)
(c)

-------------------------------

6. Is the Claimant the sole owner of the property

stolen or damaged?

7. What is the estimated value of the total contents

'of the premises at the time of the Theft 7

8.. (8) For what sum is the contents of the

premises insured against Fire?

(b) With what Company is the Fire Insurance -------- ------------------

•.
effected 7

9. Has th~ Claimant ever before sustained loss by

'Fire or by Theft? If so, brief particulars should
be>given
I,
10. Are there any other insurances against Theft
! upon the Silme property?
 I /We .. of _

___________________________ do hereby affirm and declare that

the ilbove statements and the statements contained in the within list of stolen ~r damaged articles
are ill all respects true and complete, and are made without reservation of any kind and in accordance
with the parti~ulars given in the said list I/We claim the sum of Rs I/We do
further affirm !Ind declare that, to my/qur knowledge, all the property specified in the said list was
contained in the premises at the time of the theft, and that no other person than myself/ourselves
has/have any interest in the property by bl'l"pf sale, or as owner, mortgagee ..trustee. or other-
eState -- -livl::;e, and that there are no other insurances in respect of loss by theft effected on the said
particulars
of other property by me/us. or, so far as I am/we are aware, by any other person excepte _
Insurances. and I/We undertake to refund the amount
or amounts claimed in the event of all or any of the lost articles being recovered.

Dated this dav of 198

Signature of the Claimant _

A List of all Stolen and Damaged Property must be furnished in the space provided below.

A Burglary Policy being a contract of INDEMNITY, all claims must be based upqn the_ actual value of
the articles at the time of the Burglary/Housebreaking. Theft, due allowa'lce being made for depreciation
- and wear and tear.
wear and tear
-
P.p. Deduction for ;belonged
claimed
articles or pro- or and .
~address) Cost
received Purchased
-
.
Rs-
Full description perty
of Amount (Name or receivodRs-
Rs.
I To whom the I From whom purchased Date I I