LIABILITY INSURANCE CLAIM FORM

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

As soon as Loss or Damage becomes known, the Company must be notified immediately. If any
detail or information is not readily available, please do not delay dispatch of this form and such
particulars may be sent later.

Policy Number: P/100/6002/2020/33

Claim Number: CL/100/06/2023/000567

A. INSURED:
1. Name: J.N.T.M Holdings (PVT) LTD
2. Address:
No 700,
Galle Road,
Induruwa

City: Bentota
3. Telephone Number: 034 2293600
4. Period of Insurance: From To

5. Limits of Indemnity under the policy:

B. PARTICULARS OF ACCIDENT:
1. Date & Time of Occurrence Date : 5th March Time : 00.30 AM
2. Place of accident Villa 700, car park
3. Brief description of the kind and
A car owned by the guest Mr Gamini
history of the Occurrence who arrived to Villa 700 on 4th March 2023
had parked his vehicle (motor car) in our guest
parking lot.
A fruit fell from a tree around 00:30 the next
morning had
damaged the front windscreen glass.

No of car CP KB - 6442.

This incident was witnessed by our property security

guard and was brought to attention to the hotel
manager by morning.

4. When did you first come to know of 5th Morning

the accident?

5. When was the accident reported to

you? 5th Morning

6. When was the claim first notified to

the Insurer? 5th Afternoon

Orient Insurance Ltd (PB 4720)

Head Office 133, New Bullers Road, Colombo 04, Sri Lanka Tel (+94 11) 203 0300
LIABILITY INSURANCE /FORM 005/2013 Page 1 of 3
C. PARTICULARS OF CONSEQUENCE OF THE ACCIDENT:
1. Has any person sustained any injuries Yes x No
in the accident? If so,
Give name(s) & Address (es) of such
Person(s)

State where such person(s) was/ were at

the time of accident

Has/Have the injured person(s) been Yes X No

removed to hospital or medically
attended?
If so, give particulars

2. Has the accident caused damage to Yes x No

property or livestock?
If so, give name(s) and address (es) of
the owner(s) of the property and / or
livestock, and full description of the
property, and state the nature and
extent of damage

3. Has any person made any claim upon Yes X No

you?
If so, state by whom and give full
particulars (attach a copy of the
notification received and of the bill, if
submitted)
4. Estimated amount of Claim separately Rs 478,758
under C 1, C 2 and C3
5. Give, if possible, the names of all
witnesses to the accident Name Addresses
Indrajith Desilva
Villa Manager
767 673 922

Orient Insurance Ltd (PB 4720)

Head Office 133, New Bullers Road, Colombo 04, Sri Lanka Tel (+94 11) 203 0300
LIABILITY INSURANCE /FORM 005/2013 Page 2 of 3
14th March 2023