MOBILE INSURANCE CLAIM FORM (FOR DAMAGE CLAIM)

NEW MOBILE PHONES ALL RISK COVER

Owner/Insured ________________________________________________________________________
Address - ______________________________________________________________________________
___________________________________________________________________________________________
Contact Number - ____________
___________________________________________

Email

ID

Date and Place of Loss - __________________________________________________________________

Amount
Claimed-____________________
DAMAGE/WATER/BURGLARY/THEFT/OTHER

Type

of

Loss-

FIRE/ACC.

Documents to be submitted while filing for claim(all are mandatory)1) Three Photos of the damaged handset (1 photo showing IMEI number
clearly and other 2 showing damages)
2) Photocopy of Original Bill on Claimant's Name
3) KYC documents: Self Attested Photo ID Proof of Claimant.
4) Insurance Claim Form signed by the claimant.
5) Incident Report completely filled by the claimant.
Describe Incident of Loss (Customer has to fill in his own writing )
-________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
____________________________________________________________________________________________________

___________________________________________________________________________________________
Claimants Name - _____________________________

Signature - _________________________ _____________

Date -___________________________________________
Place - ____________________________________________