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FG Pack and Protect Claim Form

Claim Form of Future Generali's Fg Pack & Protect

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shubham.sharma
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© © All Rights Reserved
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44 views4 pages

FG Pack and Protect Claim Form

Claim Form of Future Generali's Fg Pack & Protect

Uploaded by

shubham.sharma
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
You are on page 1/ 4

FG PACK & PROTECT

CLAIMS FORM
ISSUE OF THIS CLAIMS 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 additional particulars may be sent later

The claim form is to be duly filled and signed by the insured. All facts and statements must be factual, and not
influenced or biased in any favour.

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 Number_______________________________________

Period of Insurance ________________ to _______________

Claim Number_______________________________________

Geographical Limits

A. DETAILS OF INSURED/CLAIMANT

Name of the Insured


Address
City

State
Pin code
Contact details Phone Number
Mobile Number
Email ID
Brief Description of
Business /
/Occupation/Profession
Sum Insured under the
Policy (Rs.)

B. DETAILS OF LOSS/ACCIDENT

Date of Loss _____/_____/_________ Time of Loss _________A.M. / P.M.

Loss Location Address

City_______________________________State_________________________________________
Pin Code__________________________

Please provide the details of the person who discovered the loss.

Claims Form_ FG Pack & Protect UIN: IRDAN132RP0018V01202122 P a g e 1|4


Name_____________________________________________________________________________

Relationship with
Insured____________________________________________________________________________

Phone Number _________________________ Mobile Number___________________

Email ID __________________________________
Describe Cause of Loss/Damage
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________

Estimated Loss (Rs.)

WITNESS DETAILS:

Were there any witnesses to the loss / accident? (Yes) (No),


If ‘Yes’,

Name of the Person’s


Address
City

State
Pin code
Contact details Phone Number
Mobile Number
Email ID

INFORMATION TO AUTHORITY

Has the loss been reported to an Authority? .(Yes) (No),

If ‘No’, reason for not reporting___________________________________________

If “Yes”, provide details

□Fire □Police □Municipality □Other

Name of Authority

Claims Form_ FG Pack & Protect UIN: IRDAN132RP0018V01202122 P a g e 2|4


Information Report
No./Authority
Reference No. and
Date
Contact Person/s
Address
City

State
Pin code
Contact details Phone Number
Mobile Number
Email ID

C. DETAILS OF OTHER INSURANCE

Is the loss/damage covered under any other Insurance . (Yes) (No),

If ‘Yes’, specify details and attach a copy of the policy

Name of Insurer
Address
City

State
Pin code
Contact details Phone Number
Mobile Number
Email ID
Policy No.
Period of Insurance From: To:
Sum Insured (Rs.)

D. DETAILS OF OTHER INFORMATION

Do you wish to provide any other information? (Yes) (No), If ‘Yes’, specify

Declaration

I/We agree to provide additional information to the Company, if required. I/We the above mentioned,
do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statement in

Claims Form_ FG Pack & Protect UIN: IRDAN132RP0018V01202122 P a g e 3|4


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 loss/damage, any false or fraudulent statement, or any suppression or
concealment, my/our claim shall be absolutely forfeited, and the Policy shall be void, and all rights to
recover there under in respect of past or future loss/damage shall be forfeited.

Place_____________________ Signature _______________________________

Date______________________ Name of Insured/Claimant__________________________

*********END********

Claims Form_ FG Pack & Protect UIN: IRDAN132RP0018V01202122 P a g e 4|4

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