Address for Communication

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N8tiona! Insurance Company ltd.
(Subsidiary of General j,.,surance Corporation of India)
Relid. Oifice, 3. MIDDLETO~J STREET, CALCUTTA-700 071

CLAiM FORM PLATE GLASS H\lSURANCE

(The completed claim form should be returned to the issuing Office of the company within
7 days of its receipt. The company does not admit liability by issuing this form.)

Policy No.: Claim No.:

1. Name of Insured

2. Address in full

3. Breakage occured on my/our plemises

situated at \

4. Ki nd of G lass broken

Squares of Glass

5. Whether Window, Door etc.

6. Size of damaged glass

7. Cracked/broken

8. Date of Breakage

9. State causes as far as possible

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10. If wilfull, or by Stones/Motor Vehicles.
Cars. Has application been made for
recovery of the amount of damage?

11. Cost of replacement. Please attach

estimate of replaces

I ceclare the conditions of my Insurance have been fully conlplied with, and that I will act in
accordance therewith. I therefore claim the Company in respect of such breakage, according
to the terms of my pOlicy.

Date: Signature of the Insured

Form No. A 004/GPG,500m96