SBI General Insurance Company Limited

Corporate & Registered Office: Fulcrum

Building, 9th Floor, A & B Wing, Sahar Road,
Andheri (East), Mumbai 400 099.

(A joint venture between of State Bank of India and Insurance Australia Group)

________________________________________________________________________________________________________________

Registered Office: Corporate Centre, State Bank Bhavan, Madame Cama Road, Mumbai - 400 021.

ALL RISK INSURANCE 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 Number_______________________________________ Period of Insurance ________________ to _______________

Claim Number_______________________________________

A. DETAILS OF INSURED/CLAIMANT

Name as per policy__________________________________________________________________________________________________________________

Address ___________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

City_______________________________State_________________________________________Pin Code__________________________
Contact Details
Phone Number _________________________ Mobile Number___________________ Email ID __________________________________

Brief Description of Business /Office/Industry/Occupation

____________________________________________________________________________________________________

B. DETAILS OF LOSS/ACCIDENT

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

Loss Location

Address ___________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

City_______________________________State_________________________________________Pin Code__________________________

Contact Details of person/s at Loss Location

Name _____________________________________________________________________________________________________________________________________

Relationship with Insured_____________________________________________________________________________________________________________________

Phone Number _________________________ Mobile Number___________________ Email ID __________________________________

Describe Cause of Loss/Damage ___________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

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Estimated Loss (Rs.) _________________________________________________________________________________________________________________________

WITNESS DETAILS INFORMATION TO AUTHORITY

Were there any witnesses to the loss / accident? Has the loss been reported to an Authority (Yes) (No),

(Yes) (No), If ‘Yes’, If ‘No’, reason for not reporting___________________________________________

If “Yes”, provide details
Name of Person/s______________________________________________
Fire Police Municipality Other
______________________________________________
Name of Authority _______________________________________________________
Address _______________________________________________________
Information Report No./Authority Reference No. and Date
_______________________________________________________________
_________________________________________________________________________
City_________________________ State_____________________________

Pin Code______________________________________________________ Contact Person/s________________________________________________________

Phone Number _______________________________________________
Address ________________________________________________________________
Mobile Number______________________________________________ __
_________________________________________________________________________
Email ID _______________________________________________________
City_____________________________State___________________________________

Pin Code______________________________________________________

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____________________________________PinCode___________________________________________

Phone Number __________________________MobileNumber__________________________EmailID_____________________________________________

Policy No._________________________________________________________________ Period of Insurance ___________________to_________________

Sum Insured (Rs.)________________________________

D. DETAILS OF OTHER INTEREST

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Is the Insured the Sole Owner of the property? (Yes) (No), If ‘No’, specify

Nature of Interest ___________________________________________________________________________________________________________________________

Person/s who has/have interest on property ____________________________________________________________________________________________________

Address _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

City_________________________ ____________State____________________________________PinCode___________________________________________

Phone Number __________________________MobileNumber__________________________EmailID_____________________________________________

E. DETAILS OF ITEMS AFFECTED

Sl. No. Description Manufacturer Year of Identification/ Sum Date of Last Date of Expiry Cost of
of Manufacture Machine/Serial Insured Maintenance of Repair/Replacement
Equipment No. (Rs.) AMC/Warranty (Rs.)

Has the affected equipment undergone any repairs previously? (Yes) (No)
If “Yes”, the nature of such repairs

Date of Repair Nature of Repair Parts affected Cost of Repair(Rs.)

F. DETAILS OF REPAIR/REPAIRER

Is the repair being carried out in house? (Yes) (No),

If ‘Yes’, specify and submit Job-Work estimates along with Pro-forma Invoices of Spare Parts to be replaced

If “ No” specify following details

Name of the Repairer ___________________________________________________________________________________________________________________________

Name of contact person/s _____________________________________________________________________________________________________________________

Address _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

City_________________________ ____________State____________________________________PinCode___________________________________________

Phone Number __________________________MobileNumber__________________________EmailID_____________________________________________

G. DETAILS OF PREVIOUS LOSSES

Losses during the 3 preceding years

Date of Loss Claim Description and Cause of Loss Value of Loss (Rs.) Insurer

H. DETAILS OF OTHER INFORMATION

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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 _______________________________

Date______________________ Name of Insured/Claimant__________________________

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