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).Card Number & Date of Expiry

3) Details of Loss

a) Date and time of Loss
b) Details of items lost

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

4) 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