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.

1). (a) Name of the card member

(b) Address

Phone No: e-mail ID

2).Citibank Credit Card Number and date of its expiry

3).Date of loss of card

4) Date of discovery of Loss

5) Date and Time of intimation to Citibank about the loss

6) Particulars of Loss or Damage7

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

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

7) Details of loss and proof

8) 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