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 Passport claim form for Secure Your Card Insurance

1. Name of the insured in full :

2. Address & Occupation

3. Credit Card No. & its expiry date

4. When was the Passport Lost  ( State the date )

5. How was the Passport lost

6. When did you inform the Police Authorities
    (Enclose copy of intimation / complaint )

7. When did you inform the Indian Embassy.

8. Are there any other insurances on loss of Passport
    If so give full particulars

9. Amount Claimed
    To be supported by original bills and receipts

10 Copy of alternate travel documents

I hereby declare that the above facts furnished by me are true to the best of my knowledge

Date :                                                                                              Signature of the Card Member