0 ratings0% found this document useful (0 votes) 63 views2 pagesCattle - Claim Form
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content,
claim it here.
Available Formats
Download as PDF or read online on Scribd
@ BAHIA | Allianz @
Bajaj Allianz General Insurance Co. Ltd_
Claim Form
PLEASE ANSWER EVERY QUESTION AND FULLY
The issue or acceptance of this form is not to be construed as admission of liability on the part of the company
Regional/Branch Office Code
Broker/Agent Name & code [Code
Insured Details
T. Policy Number
2, Claim intimation number
3. Name of the Insured
4. Address of the Insured Building name
Plot No/Door No.
code
Mobile No.
E-mail id (if any)
Details of Cattle in respect of which claim is made
[ype of | Sex [Age Breed Description of the Cattle Tdentifi | Insured’s
Cattle cation | estimate
Details Tag | of,
of the No. | Market
Cattle Value
MIF Years Colour Moms [Tail | Distinguishing | RULt | Rs,
Switch | Features Ear
Details of the Claim- Cover 1
Nature of Disease contracted.
Date Disease was first detected
Details regarding treatment of
Disease
4 Name and contact number of Vet
attending and Performing Post-
mortem Contact Number 3. a) Date of the Death
b) Cause of Death,
©) How and where did the accident
happen?
Details of the Claim- Cover 2
© a) Nature
Disability
) Centificate from Vet obtained? If
yes, please attach.
of Permanent Total
©. Name & address of the Vet who | Name
issued the Certificate of Soundness
Address:
Contact Number
7 Name & address of the Hospital
where treatment is taken/being taken
% Do you have any other Cattle
Insurance Policy? If Yes, give details
9. Incase of Insurance of birds :
a) Record of purchase and sales
maintained by you (Yes/No) sesseeessseesseeesnseesnneennseenseeeunee
‘And it updated up to
Updated upto.
Last purchase of birds
Last Sales of birds
>) Name and contact number of
superwisor
No of birds purchased 01 jyysnnyyssss
No of birds sold 0M jy
Contact No.
WWe hereby declare that the foregoing statements are true in all respects and that I/We have not attempted to conceal from
the company anything with which it ought to be made acquainted. /We confirm my/our understanding that if we have
made or will make in any further declaration the Company may require any false or fraudulent statement or suppression or
conceal any material fact or advance any untrue fact whatever, the Policy shall be void and my/our right to compensation
forfeited and I am/ we are willing if required, to make a statutory Declaration before a Justice of the Peace of the truth of
the whole of the foregoing statement or any other statement I/We may make in connection with this claim.
Signature of the Insured
Date
Address
Date
