NATIONAL INSURANCE COMPANY LIMITED
(Regd.Office : 3, Middleton Street, Calcutta – 700 071)

FIRE CLAIM FORM

Name of Claimant …………………………………… Policy No..…………………..
Name of Insured ……………………………………………. Agency ……………………..
When did the Fire take Place ?
At the hour of ………………in the ………………
Of the ……………………….day of ………...200
Situation of property damaged or destroyed .
How were the Premises occupied at date of Fire ?
What was the cause of the Fire , and under what
circumstances did it occur ?
Does the Policy give a correct description of the
property in all respects as it existed immediately
before the Fire ?
Has any element of risk been introduced which was
not allowed by the Policy ?
Have the conditions and warranties of the Policy
been complied with in every respect ?
Is the claimant the Sole Owner of property damaged
or destroyed ?
If not, state full particulars of any other interest.
Has there been a previous Fire in these Premises or
any other Premises in which the insured was
interested ?
If so, state full particulars including the cause of
such Fire or Fires.
What was the sound value of all Properties referred
to in Item No……………..of the policy under
which the claim is made ?
NAME OF COMPANY
AMOUNT
Where there at the time of the Fire any existing
Insurances , whether effected by the claimant or by
any other person , on the said property with any
other Company ?
If so, state full Particulars , if not please write “NO”
I…………………………………………………….……now residing at ……………………………….
…………………………………do hereby declare that the above is a full, true and accurate statement
and that the articles mentioned on the other side , being my property and insured under above numbered
Policy or Policies were accidentaly destroyed or damaged without any design or procurement on my part
by the aforesaid Fire according to the extent and value annexed ; I further declare that I had not entered into
any contract to sell or dispose of the said property wherefor I claim from the Company, the sum of Rs.
Witness…………………………….. Signature of Claimant…………….…………..
……………………………. Date ………………………
The issue of this form is not to be taken as an admission of liability on the part of the Company.
Detailed Statement of Property destroyed or damaged
Destruction or Damage to Buildings – A detailed estimate by a Builder or other competent person
should be submitted in support of the amount claimed making
Due allowance for age, depreciation etc.
Destruction or Damage to Contents - A detailed statement of the various articles claimed for should
be written in here or attached to the form. The claim must be
based on the actual value of the property at the time of the fire
i.e. without any inclusion of profit and after allowance has
been made for depreciation , wear and tear etc.
Salvage : The salvage should be protected from deterioration without
removing the debris until permission given for removal.
No. Articles destroyed or damaged Value or Property of
Articles damaged or
Destroyed at the
time of the fire
Value of salvage Amount claimed
i.e. actual loss after
deduction of
salvage value