THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd & Head Office : New India Assurance Building,
87, Mahatma Gandhi Road, Bombay – 400 001

PRODUCT LIABILTY CLAIM FORM

Policy No.________
Claim No._________

The issue of this form is not to be taken as an admission of liability. The Completion and return of this form to the Company should not be delayed if any of the particular required cannot be immediately given. They may be forwarded to the Company afterwards as soon as possible.

1. (a) Name of Insured :________________________________________
(b) Address :________________________________________ ______________________________________________________________
______________________________________________________________
(c) Policy Number :_______________________________________
(d) Period of the Policy :_______________________________________
(e) Limits of Indemnity under the Policy :________________________________

2. Particulars of accident :
(a) Date of occurrence :_____________ Time :________A.M./P.M.
(b) Place of accident :_____________________________________
(c) When did you first come to know of the accident? ____________________
(d) When was the accident reported to you ?
(e) When was the claim first notified to the Insurer? ______________________

3. Particulars of consequences of the accident:
(a) Has any person sustained any injuries in the accident? If so,
(i) Give name/s , address/es and occupation/s of such person/s.
________________________________________________
________________________________________________

(ii) State where such person was at the time of accident.
___________________________________________
(iii) Have the injured persons been removed to hospital or medically attended? If so, give particulars. ____________________________________________________________________________________________________________________________________________________________________________________
(b) Has the accident caused damage to property or livestock? If so, give name/s and address/es of the owner/s of the property and/or the livestock and full description of the property and state the nature of and extent of damage.
______________________________________________________________________________________________________________________________
(c) Has any claim been made upon you by any person? If so, state by whom and give full particulars (If claim has been made in writing, attach a copy of the notification received and of the bill, If submitted) ______________________________________________________________________________________________________________________________
(d) Estimated amount of claim separately under (a), (b) and (c) _____________________________________________________________________________________________________________________________

4. (a) Give, if possible, the names and addresses of all witnesses to the accident ____________________________________________________________________________________________________________________________________
(a) Has the accident been reported to any authority? If so, state to whom and attach a copy of the report submitted. __________________________________________________________________________________________________________________________
(b) What action, if any, has been taken by the authority? __________________________________________________________________________________________________________________________
(c) Give particulars of any other insurance, if any, in respect of the same risk._______________________________________________________________________________________________________________________

I/We, the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect; and I/we agree that if I/We have made, or in any further declaration, the Company may require in respect of the said accident, shall make any false or fraudulent statement, or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and Void.

Insured’s Signature _________________

Date_________________