SBI General Insurance Company Limited
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1800 22 1111 | 1800 102 1111
www.sbigeneral.in
STANDARD FIRE AND SPECIAL PERILS POLICY
Claim Form
ISSUE OF THIS CLAIM FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY.
If any detail or information is not readily available please do not delay the dispatch of this form and such particulars may be sent later.
Policy No. Claim No.
Period of Insurance From D D M M Y Y Y Y To D D M M Y Y Y Y
A. DETAILS OF INSURED/CLAIMANT
S U R N A M E M I D D L E N A M E F I R S T N A M E
1. Name as per Policy
2. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
3. Contact Details Phone No. Mobile
E-mail Id
4. Brief Description of Business
/Office/Industry/Occupation
5. Limits of Indemnity under
the Policy (Rs.)
B. DETAILS OF LOSS/ACCIDENT
1. Date of Loss D D M M Y Y Y Y Time of Loss : a.m./p.m.
2. Loss Location Address Plot No/Door No. Building Name
Road Area
City Pincode
State
3. Contact Details of person/s at Loss Location
Name S U R N A M E M I D D L E N A M E F I R S T N A M E
Relationship with Insured
Contact Details Phone No. Mobile
E-mail Id
4. Describe Cause of
Loss/Damage
Version 1.2, Nov. 2011
5. Estimated Loss (Rs.)
a) Building b) P&M c) FFF
d) Stocks e) Others 1 f) Others 2
1
Corporate & Registered Office: ‘Natraj’, 101, 201 & 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai - 400 069.
WITNESS DETAILS
1. Were there any witnesses to the loss/accident? Yes No
If 'Yes',
2. Name as Person/s S U R N A M E M I D D L E N A M E F I R S T N A M E
3. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
4. Contact Details Phone No. Mobile
E-mail Id
INFORMATION TO AUTHORITY
1. Has the loss been reported to an Authority? Yes No
If 'No', reason for not reporting
If 'Yes', provide details Fire Police Municipality Other
2. Name of Authority
3. Information Report No./ Date D D M M Y Y Y Y
Authority Reference No.
S U R N A M E M I D D L E N A M E F I R S T N A M E
4. Contact Person/s
5. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
6. Contact Details Phone No. Mobile
E-mail Id
C. DETAILS OF OTHER INSURANCE
1. Is the loss/damage covered under any other Insurance? Yes No
If 'Yes', specify details and
attach a copy of the policy
2. Name of Insurer
3. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
4. Contact Details Phone No. Mobile
E-mail Id
5. Policy No.
6. Period of Insurance From D D M M Y Y Y Y To D D M M Y Y Y Y
7. Sum Insured (Rs.)
2
D. DETAILS OF OTHER INTEREST
1. Is the Insured the Sole Owner of the property? Yes No
If 'No', specify
2. Nature of Interest
3. Person/s who has/have
interest on property
4. Address Plot No/Door No. Building Name
Road Area
City Pincode
State
5. Contact Details Phone No. Mobile
E-mail Id
E. DETAILS OF PREVIOUS LOSSES
Losses during the 3 preceding years
Date of Loss Claim Description and Cause of Loss Value of Loss (Rs.) Insurer
F. DETAILS OF OTHER INFORMATION
Do you wish to provide any other information? Yes No
If 'Yes', specify
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 make in any further declaration, the Company may require in respect of the said accident, any false or fraudulent
statement, or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and void, and all rights to recover there
under in respect of past or future loss/accident shall be forfeited.
Place Signature of Insured/Claimant
Date: D D M M Y Y Y Y Name of Insured/Claimant
