UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO. 24 WHITES RD, CHENNAI -600 014

UNITED INDIA INSURANCE COMPANY LIMITED
CLAIM FORM FOR UNIHOME CARE POLICY
(ISSUANCE OF THIS FORM IS NOT ADMISSION OF LIABILITY)

BRANCH / DIVISIONAL OFFICE :
Policy No. Claim No.
1 Name and address of the insured (financier /
Bank)
2 Address of the Insured
3 Name of the Insured person / borrower
4 a) Permanent Address of the Insured person /
borrower
b) Address of the house property.
5 a) Occupation of the Insured person / borrower
b) Age / Date of birth
6 Period Insurance
7 Total Amount of Loan Disbursed to this
borrower
8 Sum Insured : A) House
B) Person
9 Amount of Loan outstanding as on date of loss /
accident.
10 If claim is made for loss on house property:
a) Date and time of loss
b) Cause / Nature of Loss
c) Has the loss has been reported to fire
brigade / police ? If so give details
If not give reasons for the same.
d) Extent of Loss (Complete details)
UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO. 24 WHITES RD, CHENNAI -600 014
11 If the claim is made for accidental death of
insured person / borrower:
a) Date and time of accident
b) Place of accident
c) Full description of accident
d) Name & Address (s) of witness to accident
e) Was the deceased free from infirmity at the
time of accident? If not give particulars.
f) Was the deceased under the influence of
drugs or drink at the time of accident?
g) Was the deceased under any law breaking
activity with criminal intent at the time of
accident?
h) Is the claimant satisfied that the death was
directly due to the accident.
i) Give the name and address of the Hospital /
Nursing where the deceased was treated
after the accident.
j) Please enclose the originals of
i. Death certificate
ii. Postmortem Certificate
iii. FIR / Panchanama relating to
accident
we / i confirm that the above facts / statements are correct to the best of our knowledge
and belief.
Signature of the Insured person/Nominee
PLACE: Signature of Insured
Official of financial institution.
DATE: