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

WEDDING BELLS POLICY
CLAIM FORM

1 a) Name of the Insured
b) Address
c) Occupation
d) Situation of the premises where the wedding took place
(Please furnish complete address)
a)
b)
c)
d)
2 a) State type of Loss- Expenses/Property/Legal Liability
b) Details of Loss-
(i) Date & Time
(ii) Cause of Loss
c) In case loss is due to Fire & Allied Perils, whether the
same has been reported to Fire Brigade/ Police
d) If the Loss is due to Riot & Strike/ Terrorism/Burglary,
Name of the Police Station where the complaint is
lodged with Crime No. and date
e) If Cancellation of Function:
(i) Delay details in reaching the venue by groom/
bride
(ii) Details of Death of near one
(iii) Details of Other Reasons for Cancellation
f) Legal Liability- details of claim made against the
insured including the grounds cited for the claim
a)
b)
c)
d)
e)
f)
3 Has the Insured claimed any compensation from any other
source for the same loss/damage/liability?
4 Details of other insurance policies on the property damaged
(owned / on hire)
5 Amount Claimed with full details :
1) Expenses Rs.
2) Property Rs.
3) Legal Liability Rs.
4) Details of refund, recovery of advances/deposits
(caution deposit/security deposit) availed, lost. Cite
reasons/ grounds for loss of refund/advance/deposit as
the case may be.
I / We declare that the details furnished above are correct in all aspects.
PLACE:
DATE :
INSURED’S SIGNATURE