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E&o Claim Form

The document is a Professional Indemnity Claim Form from The New India Assurance Company Limited, requiring detailed information about the insured, the incident, and the claimant. It emphasizes that submitting the form does not imply liability and outlines the necessary particulars to be provided. The form also includes a declaration regarding the truthfulness of the information provided.

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havefun4ukevin
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44 views2 pages

E&o Claim Form

The document is a Professional Indemnity Claim Form from The New India Assurance Company Limited, requiring detailed information about the insured, the incident, and the claimant. It emphasizes that submitting the form does not imply liability and outlines the necessary particulars to be provided. The form also includes a declaration regarding the truthfulness of the information provided.

Uploaded by

havefun4ukevin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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THE NEW INDIA ASSURANCE COMPANY LIMITED

Regd & Head Office : New India Assurance Building,


87, Mahatma Gandhi Road, Bombay – 400 001.
UIN NO.IRDAN190P0080100001
PROFFESSIONAL INDEMNITY CLAIM FORM
CLAIM No. ______________

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY


The completion and return of this form to the Company should not be delayed if any
of the particulars required cannot be immediately given, They may be forwarded to
the Company afterwards as soon as possible (If space found insufficient please
attach separate sheet).

1. (a) Name of Insured

(b) Address

(c) Qualification Registration No.

(d) Policy Number

(e) Period of Policy

(f) Limits of Indemnity under the policy.

2. Particulars of Incident :

(a) Date of Occurrence :

(b) Place of Occurrence :

(c) Who is directly responsible for the injury/ loss?

(d) Give details of treatment :

3. (a) Who has made the claim on you ?


(If claim has been made in writing,
attach a copy of the demand/legal
notice received and of the bill,
if any, submitted).

(b) Name and Address of the Claimant.

(c) His age and occupation.

(d) When did he first consult.

(e) General condition / status now.

(f) Give full particulars of any other


relevant aspect
4. Amount claimed as damage from you :

5. (a) Give the names and addresses of


Person who witnessed the incident :

(b) has the incident been reported


to any authority ?
If so, state to whom and attach
A copy of the report submitted. :

(c) What action, if any, has been taken


by the authority ?

6. Give particulars of other insurance


if any, in respect of the same risk. :

7. Has any claim been made upon you before.

I/We the above named, do hereby, to the best of my/our knowledge a


belief, warrant the truth of the foregoing statements in every respect; and
I/We agree that if I/We have made, or in any further declaration the
Company may require in respect of the said accident shall make 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.

Witness : Signature ________________ Insured’ s Signature ____________

Name ________________ Date ______________

Address ________________

Date ________________

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