1 Please ensure that all questions are answered in capital letters using an ink pen r e b m u N y c i l o P Name of the Insured Address for Correspondence (with Pin Code) Phone No. STD Code : Fax Mobile THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY 1. DETAILS OF THE INSURED: 2. DETAILS OF OTHER INSURANCE POLICIES COVERING THE SAME INTEREST: 3. DETAILS ON ITEM DAMAGED Issuing office :_______________________ Date of Issue :_______________________ Claim No :_______________________ MACHINERY BREAKDOWN CLAIM FORM Date & time of Occurrence NAME OF THE COMPANY POLICY NO POLICY PERIOD SUM INSURED A. Type of Machinery damaged B. Age of the damaged machinery c. Its output & capacity D. Make & Serial Number of the affected Machinery. E. Serial Number in the policy.
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PR16144 MACHINERY BREAKDOWN CLAIM FORM€¦ · Royal Sundaram General Insurance Co. Limited (Formerly known as Royal Sundaram Alliance Insurance Company Limited) Vishranthi Melaram
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Please ensure that all questions are answered in capital letters using an ink pen
rebmuN yciloP
Name of the Insured
Address for Correspondence
(with Pin Code)
Phone No. STD Code :
Fax
Mobile
THE ISSUE OF T HIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
1. DETAILS OF THE INSURED:
2. DETAILS OF OTHER INSURANCE POLICIES COVERING THE SAME INTEREST:
3. DETAILS ON ITEM DAMAGED
Issuing office :_______________________ Date of Issue :_______________________ Claim No :_______________________
MACHINERY BREAKDOWNCLAIM FORM
Date & time of Occurrence
NAME OF THE COMPANY POLICY NO POLICY PERIOD SUM INSURED
A. Type of Machinery damaged
B. Age of the damaged machinery
c. Its output & capacity
D. Make & Serial Number of the affected Machinery.
E. Serial Number in the policy.
I declare that to the best of my knowledge and belief these particulars are full and true. I agree to provide any further informationthat may be required.
Place
Date
Signature of the Insured
Please submit the following documents along with the claim form within 14 days.
Invoice/Bills
(DD/MM/YY)
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Royal Sundaram General Insurance Co. Limited(Formerly known as Royal Sundaram Alliance Insurance Company Limited)