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.

Burglary Claim form for Secure Your Card Insurance

1). (a) Name of the card member

(b) Address

 

Phone No: e-mail ID

2).Credit Card Number & Date of Expiry

3) Date and Time of loss intimation to Citibank.

4) Details of Loss

a) Date and time of Loss

b) Details of items lost

Sl No Items lost Serial No&Identification mark Bill No &Date Price
 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

c) Cause of loss

d)How did the loss take place

e)Place where loss took place

f)Where was the lost item kept at the time of loss

g)When and by whom the loss was discovered?

h)Are any family members or servants involved as principal or accessory?

i)Whether the lost item was successively recovered in full or part and if so details

5) Has any claim been lodged with any other Insurance company
     for the same loss? Claim Settlement amount, if any:

I the above named , do hereby, to the best of my knowledge and belief, warrant the truth of the foregoing statements in every respect; and I agree that if I 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 there under in respect of past or future accidents shall be forfeited.

 

Date :                                                                                              Signature of the Card Member

Witness :- (Signature)______________________

Witness’s Name__________________________

Occupation ______________________________

Address _________________________________

I have enclosed the following documents for the purpose of this claim:
 Documents attached  Strike out not applicable
 1. Notice of loss to the Company in writing. YES / NO

 2. Police Report (F.I.R.)

 YES / NO

 3. Claim form duly completed alongwith the details of items lost or damaged indicating their description, date of 
     purchase, model/make, value.

 YES / NO

 4. Non-Traceable Certificate from the Police authorites in the prescribed format in case of loss by burglary.

YES / NO
 5. Claim will be settled only on receipt of Subrogation/Indemnity letter from insured. YES / NO

 6. Bills reflecting the purchase of lost article.

 YES / NO