on : BAJAJ | Allianz @) Bajaj Allianz General Insurance Company Limited ead fice & Head Office GE Plaza, rpm Road, Yrawada, Pune = 11 006 emer FRECAIMFORM a) no (OTOL TS1=121AT VIGl 1618 TOII=[01 160 416 cris no, (For Official Use) Name of sured (ANAND. FTIRL SPIT | pistataisl lI A place es were the Premises being used atdateof | QO. 4 5 a Peppered andiieresulantdanage, [07 \e)o>|a1 rean abe caused 10 horpen |Win tw ewer g Wart vind fire argc Fo he BUS, ‘occupation atte tne of the ae Hs [ Ces One ee7. Who has witnessed the loss? Please enclose his statement. Tenant ‘What measures were taken to minimize the loss ? tyes, Please enclose the certificate from the Fire Brigade) FAR from Police ®t damages due tothe At of Gd, the lease ends the repr rom he meteorological depatnent/nensparer | WR cating Describe the incident. 1o._Hsthe Public ire Bae [Pole were informed? Be Ow CGive dates of any previous claims of a similar nature you have made, 15. Were there atthe time ofthe occurence any other existing Insurance policies onthe said Property, with any other Company or Insurer, whether effected bythe claimant or by any other Person? Details of Claim for property destroyed or damaged as reuired by the Dives xo Yes, please provide full particulars conditions ofthe company’s policies, Policy No. & Item of Policy Description of property claimed for in detail ‘Amt Insured | Market vive Toa (ere after the loss ‘Amt Claimed Residanbel elal- ab -404, at Fly, Araepl ehctrom , Str, Noite: a2beres| fo, cre0t | | 14, $8,66 ‘and sincerely dedare thatthe deals appended hereto are afl rue andcorect statement ofthe oss, sustained bythe above policy in consequence ofthe afoesadlassamauntingtothe sum ofS dinrespect of each andl ofthe several articles or tems of property damaged or destroyed, constitute their value tthe proftof any kind, and jyand sincerely declare that YWe have not ether direc orindirecty, proximately or remotely caused the said loss, : declarations conscientiously