{"id":2301,"title":"National Suroyday 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/National%20Suryoday%20Policy%20-%20Claim%20Form.pdf","sha256":"f90629ace46113998148db0908c123f2011733605a80100b6c5f8e0dfb492b0f","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant to report and claim losses under the National Suroyday Policy for various insured events such as fire, burglary, public liability, breakdown of solar power plant appliances, and terrorism cover.","notes":["Salvage should be protected from deterioration without removing debris until permission is given for removal.","The claim must be based on the actual value of the property at the time of the fire without inclusion of profit and after allowance for depreciation, wear and tear etc."],"title":"National Suroyday 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":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Broker / Agency Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Description of Loss and Claim Section","fields":[{"help":"Describe the loss in detail","type":"text","label":"Description of Loss","options":[],"required":null,"pdf_field":""},{"help":"Select the applicable section","type":"choice","label":"Please mention the section under which loss has been claimed?","options":["Section I: Fire & Allied Perils","Section II: Burglary","Section III: Public Liability","Section IV: Breakdown of Solar Power Plant Appliances","Section V: Terrorism Cover"],"required":null,"pdf_field":""},{"help":"Specify the peril if Section I is selected","type":"text","label":"Pl. specify the peril?","options":[],"required":null,"pdf_field":""},{"help":"Provide date, time, and place of loss","type":"text","label":"Date, Time & Place of Loss:","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount of loss in rupees","type":"amount","label":"Amount of Loss:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section I: Fire","fields":[{"help":"Describe location of damaged property","type":"text","label":"Situation of the property damaged or destroyed:","options":[],"required":null,"pdf_field":""},{"help":"Describe occupancy of premises at time of loss","type":"text","label":"How were the Premises occupied at date of Fire/ Loss / Damage?","options":[],"required":null,"pdf_field":""},{"help":"Explain cause and circumstances of 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 claimant is not sole owner","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 for the Property Insured? If so, state full particulars, including the cause of such Loss/Damage/Fire or Fires.","options":[],"required":null,"pdf_field":""},{"help":"State the value of the insured property","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 other insurances 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","fields":[{"help":"Describe type of premises and nearest railway station","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":"Was the premises were forcibly entered?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify part of premises from where property was taken","type":"text","label":"If Premises was forcibly entered: a. From what part of the premises was the property taken?","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of theft or last seen","type":"text","label":"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?","options":[],"required":null,"pdf_field":""},{"help":"Provide details on thief identification or evidence","type":"text","label":"c. Has the thief been identified? If not, what evidence is there that a theft has been actually committed?","options":[],"required":null,"pdf_field":""},{"help":"Mention if any suspect is known","type":"text","label":"d. Do you suspect any one?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"(a) Were the premises inhabited at the time of the theft?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide last inhabited date and time if premises were uninhabited","type":"text","label":"(b) If not, upon what date and at what hour were they last inhabited prior to the Theft?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"(a) Have the Police Authorities been informed of the Theft?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide police station, date, and FIR number","type":"text","label":"(b) If so, on what day and at which Police Station and the FIR No.?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"(c) Has any arrest been made?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide recovery details and amount if any","type":"text","label":"(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 if any","type":"text","label":"a. Has the claimant ever before sustained loss by Fire or by Theft? If so, brief particulars should be given.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other theft insurance if any","type":"text","label":"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: Public Liability","fields":[{"help":"State the indemnity limits","type":"text","label":"Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide date when accident was first known","type":"text","label":"Particulars of Accident (a) When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Provide date accident was reported","type":"text","label":"(b) When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Provide date claim was notified","type":"text","label":"(c) When the claim was first notified to the Insurer?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of injured persons","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","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details","type":"text","label":"(b) Have the injured persons been removed to hospital or medically attended? If so, give particulars","options":[],"required":null,"pdf_field":""},{"help":"Provide details of property or livestock damage","type":"text","label":"(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","options":[],"required":null,"pdf_field":""},{"help":"Provide details of claims made against you","type":"text","label":"(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).","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated claim amounts","type":"amount","label":"(e) Estimated amount of claims separately under (a), (b) and (c)","options":[],"required":null,"pdf_field":""},{"help":"List witnesses","type":"text","label":"(a) Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide authority details and attach report","type":"text","label":"(b) Has the accident been reported to any authority? If so, state to whom and attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"help":"Describe authority's action","type":"text","label":"(c) What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance","type":"text","label":"(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 IV: Breakdown of Solar Power Plant Appliances","fields":[{"help":"Provide detailed equipment information","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 discovery details","type":"text","label":"(i) If the equipment is damaged: a. By whom discovered and when:","options":[],"required":null,"pdf_field":""},{"help":"Attach repair/replacement estimate","type":"text","label":"b. Has any estimate been obtained for repairs/replacements if so, from whom? Please attach the estimate.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"c. Is there any service contract for the insured equipment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"d. Whether the damaged item is covered under warranty?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach loss report from maintenance firm or supplier","type":"attachment","label":"e. Please furnish loss report drawn up by the maintenance firm or supplier or dealer.","options":[],"required":null,"pdf_field":""},{"help":"Provide theft details and police notification","type":"text","label":"(ii) 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 details and attach repair estimate","type":"text","label":"(iii) 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 third party details if applicable","type":"text","label":"Is any third party is responsible for the loss. If so, please give the details","options":[],"required":null,"pdf_field":""},{"help":"","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":"Injured Workman Details (related to Public Liability or Workmen's Compensation)","fields":[{"help":"","type":"text","label":"Name of the Injured workman","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Religion","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Caste","options":[],"required":null,"pdf_field":""},{"help":"Specify gender","type":"text","label":"Gender","options":[],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"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":"Describe work at time of accident if different","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":"Provide employer or contractor details","type":"text","label":"Is the injured person in your direct employ? If not give name & address of Contractor","options":[],"required":null,"pdf_field":""},{"help":"Date of joining service","type":"date","label":"When did the injured person enter your service?","options":[],"required":null,"pdf_field":""},{"help":"Hospital details","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":"Hospitalization status and discharge date","type":"text","label":"State whether still in hospital, or when discharged","options":[],"required":null,"pdf_field":""},{"help":"Attach medical report or state if offered","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":"Return to work details","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":"Date and source of accident notice","type":"text","label":"Upon what date did you receive notice of accident and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Attach written notice if available","type":"attachment","label":"If in writing please attach it to his form","options":[],"required":null,"pdf_field":""},{"help":"Date work stopped","type":"date","label":"On what date did the injured person actually cease work?","options":[],"required":null,"pdf_field":""},{"help":"Describe accident circumstances","type":"text","label":"State how this accident occurred","options":[],"required":null,"pdf_field":""},{"help":"Provide machinery safety details","type":"text","label":"If from machinery (a) Whether it was fenced or guarded (b) Was it being cleaned whilst in motion?","options":[],"required":null,"pdf_field":""},{"help":"Describe work nature","type":"text","label":"What was the general nature of the contract or work going on?","options":[],"required":null,"pdf_field":""},{"help":"Describe injury","type":"text","label":"State nature of injury","options":[],"required":null,"pdf_field":""},{"help":"Specify injured body parts","type":"text","label":"State regions injured","options":[],"required":null,"pdf_field":""},{"help":"Specify side of injury","type":"text","label":"State whether right or left side","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person under the influence of drink or drugs at the time of the accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide misconduct details if any","type":"text","label":"Was he guilty of any misconduct or disobedience to orders or rules? If so, please give full particulars.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of neglect if applicable","type":"text","label":"State through whose neglect it occurred, if any","options":[],"required":null,"pdf_field":""},{"help":"List witnesses","type":"text","label":"State the names of any persons who witnessed the accident","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section V: Terrorism Cover","fields":[{"help":"Describe terrorism-related loss details","type":"text","label":"Please describe the circumstances leading to the loss and give the details of the loss:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Detailed Statement of Insured Property destroyed or damaged (For Section I)","fields":[{"help":"List articles 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 National Suroyday Policy sections: Fire & Allied Perils, Burglary, Public Liability, Breakdown of Solar Power Plant Appliances, Terrorism Cover","attachments":["Estimate for repairs/replacements (Section IV)","Loss report drawn up by maintenance firm or supplier or dealer (Section IV)","Written notice of accident (if any, Injured Workman section)","Copy of notification and bill if claim made in writing (Section III)","Copy of police report (Section III and Section II if theft reported)"],"declarations":["The claimant declares that the statement is full, true and accurate.","The articles mentioned are the claimant's property and were accidentally destroyed or damaged without any design or procurement by the claimant.","The claimant has not entered into any contract to sell or dispose of the property for which claim is made.","The issue of this form is not an admission of liability by the Company."],"dropped_labels":1},"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/2301-national-suroyday-policy-claim-form"}