The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

Pedal Cycle Claim Form
The issue of form is not to be taken as an admission of liability

Claim No. ___________

Policy No._____________

Answer all questions and fully. It will avoid unnecessary correspondence and consequent delay in the settlement of claim.

1. Name of Insured (in full)

2. Address

3. Occupation

4. The insured Pedal Cycle:
(a) Mark.....................(b) Maker's No...........................(c) Regd. NO................. (d) Price paid by the Insured Rs..................(e) Year of Manufacture.................... (f) Date of purchase/whether purchased New or Second Hand............(g) Purpose for which it is generally used..............................................(h) Purpose for which it was being used at the time of accident...................................................................... (i) Was it in proper order & condition at the time?................................................ (j) Was it being used with your knowledge & consent?......................................... (k) Whether a Pinion passenger was being tamed at the time of accident.................

5. The Driver
(a) Full name of the person who was driving the Cycle at the time of accident?.............. (b) His age....................... (c) His full address.........................................................
..................................................................................................................... (d) Is he your regular employee? ...........................................................................

6. The accident: (Damage/ Fire/Theft)
(a) Date of Occurrence.....................................(b) Time......................................... (c) Place (Street or Road &Town)............................................................................ (d) When was it reported to you?........................................................................... (e) What was the width of the street...................................................................... (f) Give full details as to the nature and cause of the Accident/Theft/Fire....................
...................................................................................................................
...................................................................................................................

7. The Damage
(a) Give in details the extent of all damage to the insured cycle directly due to the accident....................................................................................................... (b) Estimated cost Rs..........................................................................................
(c) Where can the cycle be inspected?...................................................................
(d) Have you given instructions for repairs to be carried out?
If so, to whom (Name & Address).......................................................................
.....................................................................................................................
(e) Have you instructed them to send an estimate to the company?...........................

N.B: If possible an estimate of repairs should be attached to this form and any event it must be sent to the Company without undue delay.

8. (a) Has the accident caused any injury to any person/persons ?...................... If so, give the following particulars: -

Name..................................................................................................................

Address...............................................................................................................
...........................................................................................................................

Occupation.........................................................................................................

Nature of injury..................................................................................................

(b) If any injured person has been removed to a hospital or medically attended, give name & address of the Hospital or Doctor............................................................................

9. General
(a) Has any claim been made upon you by any Third Party? If so, give details and attach intimation.............................................................................................................
(b) If accident was caused by the fault of any third party, give name and address of such person/s...............................................................................................................
(c) Give the following particulars about all witness to the accident: Name.....................
Address.................................................................................................................
(d) Was the matter reported to the Police? If so, give name of the Police Station.............
(e) What action, if any, was been or is being taken by the policy or any other authority.....
..............................................................................................................................
(f) Give particulars of other insurance on the cycle, if any..............................................

I/We the above named do hereby to the best of my/our knowledge and behalf, warrant the truth of the foregoing statements in every respect: and I/we agree that if I/We shall make or in any further declarations, the Company require in respect of the said accident shall make any false or fraudulent statement or any suppression or concealment the Policy shall be void and all rights to recover thereunder in respect of past or future accidents shall forfeited.

Date...............................................

Place..............................................

Witness:.............................................

Address: ............................................ Signature.........................................
.................................................