Fire Claim Form
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1
2Bajaj Allianz General Insurance Company Limited
Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune - 411 006
FIRE CLAIM FORM
FIRE CLAIM FORM
Policy No.
Claims No. :
(For Official Use)
Name of Insured
Business Address
Home address
Tel No.(O)
Mobile
e-mail
1.
What was the nature of the occurrence and when did it take
At
p.m. on
a.m.
place?
2.
At what address did it take place?
3.
For what purposes were the Premises being used at date of
occurrence ?
4.
Describe briefly what happened and the resultant damage,
and state what you believe caused it to happen
5.
Were the Premises and their occupation at the time of the
Yes
No
occurrence exactly as described in the Policy ?
Had any element of risk been introduced which was not
Yes
No
allowed by the Policy ?
6.
Is the Claimant the Sole Owner of the property damaged or
Yes
No
destroyed ?
If not, state full particulars of any other Interest
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