National Insurance Company Limited

(Incorporated in India, subsidiary of General Insurance Corporation of India)

(Regd. Office : 3, Middleton Street, Calcutta – 700 071)
The Issue of this form is not to be taken as an admission of liability.
Policy No.__________________ Claim No._______________
Burglary Insurance Claim Form
Notification of Physical Loss or Damage

A Name, Address, Telephone Number, Contact Person and

Email Address

B Occupation
1. Full Address of Premises broken into
C

2. The day and hour the Premises were broken into

3. How the entrance was affected?

4. Which rooms were entered?

1. Whether the premises were inhabited at the time

D
of the Burglary?

2. If not, for what periods have they been

Uninhabited since the last premium was due?

When did you inform the Police Authorities of the theft and
E
at Which Police Station? Please provide copy of the FIR.

Are you the sole owner of the property damaged or stolen?

F
State the estimated value of the total Contents of the
G
premises at the time of The Burglary.

Also please attach the list of items stolen.

For what sum you insure the contents against Fire and with
H
which company?
Are there any other insurance upon the same property? If
I
so, give full particulars with name of the insurance
company and the sum insured set against the assets. Also
 provide copy of such policies.
Have you ever before sustained loss by under your fire and
J
burglary policies? If so, give particulars.

I / We above named being insured under the above Policy do hereby declare and setforth that at or
about_______________________ O' clock a.m. / p.m. on the ___________ 19 _____ a theft was committed at above described
Premises in the manner stated and articles enumerated in the within list and valued at sum or Rs. _________________ were stolen
therefrom and I / we further declare that no other person has any interest in the said property, as Owner Mortgage, Trustee or
otherwise, and that it is not otherwise insured against Burglary, with this or any other Office, except as above stated. The undersigned
policyholder declares to have answered the above questions conscientiously and faithfully and he is liable for the correctness and
completeness of his statement.

PLACE:

DATE: Signature of Insured

(Stamp of company required)

Witness my / our hand this_____________ day of ______________ 200 ____.

Witness (Sign.)
Name
Address