Case Ref.

: DOS:
OBSERVATION SHEET - TELECOM
Name of Insured
Site ID
Address

Date of Loss
Cause of Loss
Date of Survey
Site Guarded or not
Owner of land Site
Type of Tower
Height of Tower
Type of Shelter
Whether site was in During Survey At the time of incident
operation
Insured
Representative’s
name, Designation
& Mobile No.
Fire Brigade report Yes No FIR Lodged Yes No
Name of Police
Station / where
intimation given.
Distance between
site of loss to police
station.
Site Sharing Details
Whether loss
sustained by
operator sharing
the site or not

Reinstatement Yes No
Reinstated with New Item Used Item Shifted From Other Site

Description of
Reinstated Item

OS TELECOM - FIRE / THEFT

LIST OF DAMAGED ITEMS

List of Damaged / Theft Items

Sr.
Item Description with Type, Sr. No. & Make Qty
No.

OBSERVATIONS: Documents Provided

• Insured’s
Statement

• Cause of Loss

• FIR & Fire

Brigade Report

• Purchase / Sale
Bills

• Stock Register

• List of damaged
items

(For Protocol Insurance & Loss Assessors Pvt. Ltd.) (For Insured…………………………………….)

Name : Name :

Date : Date :

Signature : Signature :

OS TELECOM - FIRE / THEFT