{"id":2297,"title":"National MSME Package Insurance Policy CLAIM FORM","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/MSME%20Package%20-%20Claim%20Form.pdf","sha256":"607221c19503d79fdfecb7c4d8f20e9af89d8557ed1686a0a65948a485287ef6","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant (policyholder or insured) to file a claim under the National MSME Package Insurance Policy for various types of losses including fire, burglary, loss of profit, electronic equipment damage, public liability, and employee compensation.","notes":["The issue of this form is not an admission of liability by the Company.","For Section I claims, submit a detailed estimate by a builder or competent person allowing for age and depreciation.","For contents, claim must be based on actual value at time of fire after depreciation and wear and tear.","Salvage should be protected from deterioration and not removed until permission is given.","Statement of wages must be completed carefully as per instructions to avoid delays.","Attach all relevant estimates, reports, FIR copies, and medical reports as applicable."],"title":"National MSME Package Insurance Policy CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant and Policy Details","fields":[{"help":"","type":"text","label":"Name of the Claimant:","options":[],"required":null,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured:","options":[],"required":null,"pdf_field":""},{"help":"If applicable, enter your broker or agency code","type":"text","label":"Broker /Agency Code:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Description of Loss","fields":[{"help":"Describe the loss in detail","type":"text","label":"Description of Loss","options":[],"required":null,"pdf_field":""},{"help":"Select the relevant section of the policy under which you are claiming","type":"choice","label":"Please mention the section under which loss has been claimed?","options":["Section I: Fire (specify the peril)","Section II: Burglary & Housebreaking","Section III: LOP","Section IV: Electronic Equipment","Section V/ VI: Public Liability","Section VII: Employee Compensation"],"required":true,"pdf_field":""},{"help":"Provide date, time, and location of the loss","type":"text","label":"Date, Time & Place of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Enter the amount of loss in rupees","type":"amount","label":"Amount of Loss (Please √)","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section I: Fire","fields":[{"help":"Describe the location of the damaged property","type":"text","label":"Situation of the property damaged or destroyed.","options":[],"required":null,"pdf_field":""},{"help":"Explain the use or occupancy of the premises at the time of loss","type":"text","label":"How were the Premises occupied at date of Fire/ Loss / Damage?","options":[],"required":null,"pdf_field":""},{"help":"Describe cause and circumstances of the fire","type":"text","label":"What was the cause of Fire, and under what circumstances did it occur?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the policy give a correct description of the Property in all respects as it existed immediately before the Loss / Damage?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any element of risk been introduced which was not allowed by the Policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have the conditions and warranties of the Policy been complied in every respect?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if ownership is shared","type":"text","label":"Is the claimant the Sole Owner of property damaged or destroyed? If not, state full particulars of any other interest","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any previous losses","type":"text","label":"Has there been a previous Loss/Damage/Fire in these Premises or any other Premises in which the Insured was interested? If so, state full particulars, including the cause of such Loss /Damage/Fire or Fires.","options":[],"required":null,"pdf_field":""},{"help":"Enter the value of the insured property before loss","type":"amount","label":"What was the sound value of all Properties referred to on Item No. ......................of the Policy under which the claim is made?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance on the property or write 'No'","type":"text","label":"Where there at the time of the Loss/Damage/ Fire any existing Insurances, whether effected by the claimant or by any other person, on the said Property with any other Company? If so, state full Particulars, if not please write “No”. Name of Company Amount","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section II: Burglary & Housebreaking","fields":[{"help":"Describe the type and location of premises","type":"text","label":"State whether private house, godown, sale-shop,*flat hotel, etc. outbuilding thereof (nearest railway station)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"If the premises were forcibly entered?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details about the theft and thief if known","type":"text","label":"If Premises was forcibly entered : a. From what part of the premises was the property taken? b. At what date and hour (if known) was the Theft committed? If not known, when was the stolen property last seen prior to the Theft? c. Has the thief been identified? If not, what evidence is there that a theft has been actually committed? d. Do you suspect any one?","options":[],"required":null,"pdf_field":""},{"help":"Provide police report details and recovery information","type":"text","label":"(a) Have the Police Authorities been informed of the Theft? (b) If so, on what day and at which Police Station and the FIR No.? (c) Has any arrest been made? (d) Has there been any recovery? If Yes, please provide amount of recovery.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the claimant the sole owner of the property stolen or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of previous losses and other insurance","type":"text","label":"a. Has the claimant ever before sustained loss by Fire or by Theft? If so, brief particulars should be given. b. Are there any other insurance against Theft upon the same property? If so, please provide details.","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section III: Fire Consequential Loss (Loss of Profit)","fields":[{"help":"Describe loss of production or turnover","type":"text","label":"Has Production/Turnover been lost (Give details)","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated date for resumption","type":"date","label":"By when is the normal production estimated to be resumed?","options":[],"required":null,"pdf_field":""},{"help":"Enter estimated financial loss","type":"amount","label":"What is the estimated loss of turnover/production during the period of interruption?","options":[],"required":null,"pdf_field":""},{"help":"Describe any additional costs incurred","type":"text","label":"Have you incurred any increased cost of working to minimize loss?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of prior claims if applicable","type":"text","label":"Details of Previous Losses - Give details of Previous Claims, if any, on the affected equipment.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section IV: Electronic Equipments Insurance (Installed)","fields":[{"help":"Provide detailed description of the equipment","type":"text","label":"The details of the equipment damaged/lost (a) Serial No (b) Name of Manufacturer and make (c) Description of the machinery like (like capacity, r p m etc.) (d) Sl. No of the policy schedule under which it is covered","options":[],"required":null,"pdf_field":""},{"help":"Provide theft details and police notification info","type":"text","label":"If by theft: 1. Time and date 2. How committed 3. By whom discovered & when 4. Have Police been notified if so, when Give address of the Police Station","options":[],"required":null,"pdf_field":""},{"help":"Provide fire incident details and attach repair estimates","type":"text","label":"In case of Fire: (a) By whom noticed and when (b) How did the fire start (c) Has estimate for repairs been obtained if so, please attach estimate.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any third party responsible","type":"text","label":"Is any third party is responsible for the loss. If so, Please give the details","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other insurance covers this loss","type":"yes-no","label":"Are you insured against the present loss under any other policy","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section V & VI: Public Liability","fields":[{"help":"State the indemnity limits under your policy","type":"text","label":"Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide dates related to accident awareness and reporting","type":"text","label":"Particulars of Accident: (a) When did you first come to know of the accident? (b) When was the accident reported to you? (c) When the claim was first notified to the Insurer?","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed information about injuries, damages, claims and estimates","type":"text","label":"Particulars of consequences of the Accident: (a) Has any person sustained any Injuries in the accident? If so, (i) Give name/s, address/es and (ii) Occupations of such person/s (iii) State where such person was at the time of accident (b) Have the injured persons been removed to hospital or medically attended? If so, give particulars (c) Has the accident caused damage to 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 of extent of damage (d) Has any claim been made upon you by any person? If so, state by whom and give full particulars (if claim has been made in writing, attach a copy of the notification received and of the bill, if submitted). (e) Estimated amount of claims separately under (a), (b) and (c)","options":[],"required":null,"pdf_field":""},{"help":"Provide witness details, authority reports and other insurance info","type":"text","label":"(a) Give, if possible, the names and addresses of all witnesses to the accident. (b) Has the accident been reported to any authority? If so, state to whom and attach a copy of the report submitted. (c) What action, if any, has been taken by the authority? (d) Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section VII: Employees Compensation","fields":[{"help":"","type":"text","label":"Name of the Injured workman","options":[],"required":null,"pdf_field":""},{"help":"Provide demographic details of injured worker","type":"text","label":"Religion Caste Gender Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Local Address of the Injured worker","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name & Address of Father","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State occupation in which the injured person is employed","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Was the injured person engaged in this occupation when the accident occurred? If not State fully the nature of the work he was doing at the time of the accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Is the injured person in your direct employ? If not give name & address of Contractor","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"When did the injured person enter your service?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and address of hospital taken to","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"In or out-patient","options":["In-patient","Out-patient"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State whether still in hospital, or when discharged","options":[],"required":null,"pdf_field":""},{"help":"Attach medical examination report if available","type":"text","label":"Has the injured person been medically examined If so, please send report. If not, was free medical examination offered?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State whether returned to work, and if so, when","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you satisfied that the injured person has met with a bona-fide accident of employment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the injured person able to do partial work?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Estimate duration of disablement","type":"text","label":"What is the probable period of the disablement (approximate)?","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed accident and injury information","type":"text","label":"Upon what date did you receive notice of accident and from whom? If in writing please attach it to this form. On what date did the injured person actually cease work? State how this accident occurred. If from machinery (a) Whether it was fenced or guarded (b) Was it being cleaned whilst in motion? What was the general nature of the contract or work going on? State nature of injury. State regions injured. State whether right or left side. Was the injured person under the influence of drink or drugs at the time of the accident. Was he guilty of any misconduct or disobedience to orders or rules? If so, please give full particulars. State through whose neglect it occurred, if any. State the names of any persons who witnessed the accident.","options":[],"required":null,"pdf_field":""}],"filled_by":"employer"},{"title":"Statement of Wages","fields":[{"help":"If wages were paid to someone else, specify who","type":"text","label":"(a) Were the above stated wages paid, or fallen due for payment, to the injured person If not, State to whom","options":[],"required":null,"pdf_field":""},{"help":"Provide absence details if applicable","type":"text","label":"(b) Was the injured person absent from work at any time, during the above stated period, for 14 or more consecutive days? If so, give the following particulars: Absent for ... days from ... to ... (multiple entries)","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Employer must sign here","type":"signature","label":"Signature of the Employer","options":[],"required":null,"pdf_field":""}],"filled_by":"employer"},{"title":"Declaration by Claimant","fields":[{"help":"Name of witness","type":"text","label":"Witness","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Claimant must sign here","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Detailed Statement of Property destroyed or damaged (For Section I)","fields":[{"help":"List each article destroyed or damaged with values and salvage details","type":"table","label":"Sl. No Articles destroyed or damaged Value of Property of Articles damaged or destroyed at the time of the fire Value of Salvage Amount Claimed i.e. Actual loss after deduction of Salvage value","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Claims under the National MSME Package Insurance Policy including sections for Fire, Burglary & Housebreaking, Loss of Profit, Electronic Equipment, Public Liability, and Employee Compensation","attachments":["Estimate by a Builder or other competent person for destruction or damage to buildings","Detailed statement of various articles claimed for destruction or damage to contents","Estimate for repairs/replacements for electronic equipment damage","Loss report drawn up by maintenance firm or supplier for EDP system damage","Copy of FIR and police report if theft or accident reported","Medical examination report for injured person (if available)","Written notice of accident (if in writing) attached to form"],"declarations":["The claimant declares that the statement is full, true and accurate and that the property was accidently destroyed or damaged without any design or procurement.","The claimant declares that they had not entered into any contract to sell or dispose of the said property for which the claim is made."],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/national-insurance/2297-national-msme-package-insurance-policy-claim-form"}