THE NEW INDIA ASSURANCE COMPANY LIMITED

    THE NEW INDIA ASSURANCE COMPANY LIMITED
DIVISIONAL OFFICE - 712500
   Allied Mount Casa Blanca Building, 2nd Floor, 260 Anna Salai, (Old No. 702),CHENNAI-600 006.
                  Phone 044-23456824/26/27   Fax : 044-23456825 Email: nia25@vsnl.com
website : www.nia25.com

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
AND SUBJECT TO VALIDITY OF THE CITIBANK CARD AS ON THE DATE OF ACCIDENT.

Loss of Baggage Claim form for Secure Your Card Insurance

1. (a) Name of Passenger in full:

(b) Address

2) Date of Loss

3) Credit Card Number and its expiry date

4) Date and time of intimation of loss to citibank

5) Particulars of Loss or Damage

(a) Nature of Loss or Damage

(b) When and by whom discovered

(d) How caused

    (e) If occurred whilst the Baggage/s was/were in the
          possession or custody of any other carrier or party,
          state what steps, if any have been taken to fix responsibility

    (f) If due to theft, pilferage or other
         criminal act, state whether reported to the Police and at
         which Police Station:

(g) What action if any, has been taken in the matter

6) Was the baggage also insured against loss or damage
with any other Insurance Company or underwriter ?
If so, state

(a) By whom
(b) With whom
(c) Amount of insurance
(d) Whether any claim has been paid by or made against the Insurance
Company or Underwriter concerned.

7) Has any claim been lodged with the Carriers or Clearing Agents or
any other party who may be responsible for the loss and, if so
with what result ?

8) Amount of compensation paid by Airlines

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 require in respect of the said accident, shall make any false or fraudulent statement, or any suppression or concealment the Policy shall be void all rights to recover threreunder in respect of past or future accidents shall be forfeited.

Date : Signature of the Card Member

I have enclosed the following documents for the purpose of this claim:

Documents attached	Strike not applicable
1. Notice of loss to the Company in writing.	YES / NO
2. Police Report (F.I.R.) wherever necessary.	YES / NO
3. Claim form duly completed alongwith the details of items lost indicating their description, date of purchase, model/make, value.	YES / NO
4. Property Irregularity Report from the concerned Airlines (either Original or Notarised).	YES / NO
5. Certificate from the concerned Airline clearly mentioning non-delivery of checked baggage and the amount of compensation paid.	YES / NO
6. List of items in the unit of baggage lost with the year of purchase and value thereof.	YES / NO
7. Proof of purchase such as bills and cash memos /Citibank charge slips or card statements inrespect of items lost.Whereever such proof is not available the indemnity will be subject to 25%	YES / NO
8. Baggage receipt token and ticket / boarding pass	YES / NO