CLAIM FORM - The New India Assurance Co. Ltd.

*Please attach discharge card, bills, cash memos, diagnostic reports etc.SECTION IIPERSONAL ACCIDENT COVER TO EARNING HEAD OF THEFAMILYName of the insured:SexAge:Date of accident:Date of death:Details of accident in brief:Date of intimation to Police:Please submit FIR & Post Mortem Report____________________________________________________________I declare that to the best of my knowledge all particulars contained in formare trueDate:Signature of the Claimant/NomineePlace:______________________________________________________________________For Office Use Only:SECTION IAmount:A) Claim under Hospitalisation:B) Claim for Disability CompensationC) Claim under Maternity BenefitSECTION IIPA CLAIM FOR DEATHTotal:2