THE NATIONAL INSURANCE COMPANY LIMITED
Regd & Head Office : 3, MIDDLETON STREET, KOLKATA – 700 001.
The Issue of this form is not to be taken as an admission of liability.
Policy No. Claim No._______________
MACHINERY INSURANCE
Notification of Physical Loss or Damage
Name ________________________________________________________________
Address ______________________________________________________________
Question Answers
1. When did the loss or damage occur ?
(State date and hour)
2. Give the name and address of the witness
to the occurrence.
3. What was damaged ?
(a) Item of the Inventory (a)
(b) Sum Insured (b)
(c) Type of machine output of capacity (c)
(d) Manufacturers and year of manufacture (d)
(Full details on maker's plate to be
given)
(e) What is the cost of replacement of the (e)
machine by a new machine of the same
size and capacity.
4. (a) Was the property brand new or second (a)
hand ?
(b) What was the last occasion before the (b)
damage when the machine was over-
hauled or attended to for maintenance
or damage
5. Is the damaged property totally destroyed ?
Questions Answers
6 What has occurred and which parts
of the property are damaged to such
an extend the replacement is
necessary?
7 Has the period of guarantee
expired?
If so, when ?
8 What is the estimated amount of
loss or
Damage?
9 What was the cause of the damage
and how did it occur?
(This question must be answered in
detail and a sketch given wherever
possible)
10 (a) Has the property undergone any (a)
repairs
previously (b)
(b) What was the nature of such
repairs ?
11 Give the name and address of the
workshop where repairs will be
executed :
(Provisional repairs will be
indemnified)
As soon as loss or damage has become known the Company at its Head Office
must be notified without delay on the present form. The Agents are not authorized to
accept notification of loss or damage.
The undersigned policyholder declares to have answered the above questions
conscientiously and faithfully and he is liable for the correctness and completeness of
his statement.
_________________ 20_____ ________________________
Signature
1. What has occurred and which parts of the
property
ECS Details of the Insured
1 Name of the Insured (as appearing in the
Bank Account)
2 Bank Name
3 Branch and address
4 Bank Account No.
5 Bank Account Type
6 IFSC Code
7 MICR Code
REGD OFFICE : 3, MIDDLETON STREET, KOLKATTA – 700 071
