ADDRESS OF POLICY

ISSUING OFFICE

CLAIM FORM
Cattle & Livestock Insurance
 Name of Borrower/ Insured: ……………………………………………………………………………………..

 Son / Wife of: ………………………………… Vill. ………………………… Dist. ……………………………

 Policy No. ………………………………………………………………………………………………………..

 Bank’s Name & Branch: ………………………………………………………………………………………..

 Schemed or Non-schemed: …………………………………………………………………………………...

 (Period) From………………………………………….to …………………………………………………...

Tag No Specie & Sex & Natural Date & Time Place of Death and Claim
Breed Age Identification of Death Cause of Death/PTD Amount
mark (in Rs.)

1. First time animal found to be diseased on Dt. ………………………………. and treated by authorised
Veterinary Doctor on Dt. ………………………………………

2. Name & Address of treating Veterinary Doctor ………………………………………………………………………..

……………………………………………………………………………………………………………………………….

Date : …………………………. Name & Signature Signature Signature & Seal

of Witness of Policy Holder of Bank Manager

Note: 1. In the event of any claim intimation to the Bank, Bank should hand over the
Claim form after filling the Name of the Policy Holder, Name of Bank and Date of
Intimation. The same should be entered in the Bank’s Insurance Register Book.
2. Kindly ensure that all the information and documents should come together for
timely settlement of claim.
 DEATH CERTIFICATE / PANCHNAMA
(FOR SCHEME ANIMALS ONLY)

I/We certify that, the animal bearing Tag No…………………belonging to Shri/Smt …………………………
………………………….. Son / wife of ..........................................., Vill……..………………………………….
Tal : …………………….., Dist. :………………………… has been found dead on Dt. ……………………….
at ……………………..
Tag No Specie & Sex , Age & Natural Place of Death and Cause Value of animal
Breed colour Identification of Death prior to death
mark (Amount in Rs.)

I, physically inspected I, physically inspected

the above mentioned the above mentioned
dead animal with tag on dead animal with tag on
dt. ………… at …………… dt. ………… at ……………

Signature / finger print Signature & Seal of Signature & Seal of

of policy holder authorised officer authorised officer
Two authorised officers in Panchnama must be from the following list of officials.1- Village Sarpanch or
Panchayat Secretary, 2- Govt. Veterinary Doctor,3- Branch Manager / Supervisor of central Co-operative
Bank, 4- Head Master of Govt. High School, 5- Head of Co-operative Society / Head of Milk collection
centre, 6- Revenue officer or Patwari.

BANK CERTIFICATE
We certify that, the animal described above bearing Tag No……………………….belonging to Shri/Smt.…………………..
……………………………………….of village……………………… is insured under Master Policy No/Policy No……………The
insured is a beneficiary under ……………………………. scheme /The Insured is not a beneficiary under any Government
scheme. The dead animal/carcass has been inspected by our officer Mr…………………………………on Dt. …………………

Along with we are sending all the following documents required for claim settlement
1. Completely filled Claim form.
2. Health certificate given at the time of purchase of the animal.
3. Death certificate / Post-mortem report given by Veterinary Doctor. ( For Non-scheme animals)
4. Valuation Certificate of the animal given by Veterinary Doctor. ( For Non-scheme animals)
5. Completely filled Panchnama. ( For Scheme animals)
6. Total no of tags …… and their number as
follows………………………………………………………………………………
7. Photograph of dead animal with tag.
8. Any other document…………………………………………………………………..

Date : Signature with Seal

Bank Manager
 VETERINARY CERTIFICATE / POST-MORTEM REPORT

I hereby certify that the animal described below, belonging to Shri/Smt..............................................................

Of Village ………………………………….. died on Dt. …………………………… which was being attended by me
from Dt. ……………………………. to Dt. …………………………….. and I have conducted Post-mortem of the said
animal on Dt. ………………………………….. to ascertain the cause of death.
.

DESCRIPTION OF ANIMAL:
Tag No Specie & Sex , Age & Natural Place of Death and Cause Value of animal prior to
Breed colour Identification of Death death (Amount in Rs.)
mark

In the case of death of the animal:

1. Whether Post-mortem conducted? If yes, submit report in the attached pro forma
2. Cause of Death: ………………………………………………....................................................................................
3. If from disease, Name of the disease & period since suffering...............................…………………………………
4. If from accident. Where did it occur and nature of injuries……………………………………………………………..
5. If from an operation, give date and nature of operation ……………………………………………………………….
6. Had animal been provided every care and attention?............................................................................................
7. Was the carcass matched and identified with the particulars mentioned in the policy?.........................................
8. In case of Milch animals please state:
(a) Date of last calving……………………………………
(b) Number of months the animals was/is pregnant………………………………………………………..
(c) What was/is the milk yield per day at the starting of lactation…………………………………………
(d) What was the milk yield per day prior to death………………………………………………………….
In case of Permanent Total Disablement (PTD):
1. In case of disablement, describe the nature of injury, disease and state when it occurred and its duration
………………………………………………………………………………………………….…………………….............
...............................................................................................................................................................................
2. Has the injury / disease resulted in permanent incapacity to conceive or yield milk or to breed?
3. Did you treat the animal for the injury/disease? If so, what was the nature of treatment given to prevent the
permanent incapacity to conceive or yield milk or breed?

I hereby certify that the above particulars are, to the best of my knowledge and belief, true and accurate
and that no information which ought to be given has been withheld by me.

Date: Signature with seal

Address:
Qualification
The form should be completed without delay and forwarded direct to the Company.
 CLAIM PROCESSING NOTE

1. Name of the Insured: …………………………………………………………

2. Policy period from ……………………… to …………………………………
3. Financing Agency/Scheme/Amount & Subsidy :……………………………
4. Date & Time of Loss : ………………………………………..
5. Date & Time of Intimation of Claim: ………………………………………..
6. Date of Post-mortem Conducted: …………………………………………..
7. Health Certificate Issued by: ………………………………………………..
8. Post-mortem conducted by: ………………………………………………………………………….
9. Whether the claim falls within the scope of policy?...................................................................
10. Whether the sec. 64 VB has been complied? …………………………………………………….
11. Whether the identification of animal given in proposal from/health certificate matches with the
identification details given in post-mortem report Yes/No.

(if no please state the difference) ……………………………………………………………….

12 Whether the animal was found tagged at the time of death/post-mortem/Inspection … Yes/No

13 Whether tag is collected: yes/No

14 If yes, Tag No. ………………………………

15 Sum Insured ………………………………………

16 Any recommendation/Comments …………………………………………………………………………..

Claim passed for payment of Rs…………................

Date: Authorised Officer

Place: