{"id":965,"title":"CLAIM FORM","purpose":"claim","insurer":{"slug":"new-india-assurance","name":"The New India Assurance Company Limited"},"source_pdf":"https://www.newindia.co.in/assets/docs/know-more/miscellaneous/advance-loss-of-profit-lns/Claim%20Form.pdf","sha256":"d65dbfd903494c51ceb95a71a6d0b0626be6d8dfece1b354d1e87001693df313","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons to report and claim losses or damages under their insurance policy with The New India Assurance Company Limited.","notes":[],"title":"CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of insurance period","type":"date","label":"Period of Insurance From To","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Insured[s]","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of Insured[s]","options":[],"required":null,"pdf_field":""},{"help":"Provide mobile number and email address","type":"text","label":"Contact Details Mobile No. & Email ID","options":[],"required":null,"pdf_field":""},{"help":"Describe the insured's interest in the property if not sole owner","type":"text","label":"If insured is not sole owner : the nature of his/their interest in the property","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other interested party","type":"phone","label":"Mobile No","options":[],"required":null,"pdf_field":""},{"help":"Email ID of other interested party","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"Enter the EAR/CAR policy number if applicable","type":"text","label":"State the EAR/CAR Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of EAR/CAR policy period","type":"date","label":"State the EAR/CAR Policy Period From To","options":[],"required":null,"pdf_field":""},{"help":"Describe the construction or erection works briefly","type":"text","label":"Brief Description of Construction / Erection works to be carried out.","options":[],"required":null,"pdf_field":""},{"help":"Select one option describing the project type","type":"choice","label":"Is the Project : I] An extension of existing work Ii] A New Venture.","options":["An extension of existing work","A New Venture"],"required":null,"pdf_field":""},{"help":"Enter start and expected completion dates","type":"date","label":"Date of Commencement of work and anticipated date of completion [ handover following constructions or testing / commissioning]","options":[],"required":null,"pdf_field":""},{"help":"Enter testing period start and end dates","type":"date","label":"Testing Period From To","options":[],"required":null,"pdf_field":""},{"help":"Enter scheduled start date of insured business","type":"date","label":"Schedule date of commencement of Insured business","options":[],"required":null,"pdf_field":""},{"help":"Enter date when full production is expected","type":"date","label":"At which date after completion of testing / commissioning is full production to be reached?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Loss Details","fields":[{"help":"Provide date and time of loss or damage","type":"date","label":"When did the loss or damage occur? Date Time","options":[],"required":null,"pdf_field":""},{"help":"Provide address where loss occurred","type":"text","label":"Loss Location Address","options":[],"required":null,"pdf_field":""},{"help":"Describe cause and circumstances of damage in detail; attach sketch if possible","type":"text","label":"What was the cause of the damage? How did it occur? (This question must be answered in detail and a sketch given wherever possible)","options":[],"required":null,"pdf_field":""},{"help":"Explain any allowances for delays caused by the accident","type":"text","label":"What allowance exists for delays due to accident?","options":[],"required":null,"pdf_field":""},{"help":"Select all damaged items and specify others if any","type":"checkbox","label":"Which items were damaged? [i] Civil Engineering Work [ii] Machinery Installation Work [iii] Any other project Material, please specify.","options":["Civil Engineering Work","Machinery Installation Work","Any other project Material"],"required":null,"pdf_field":""},{"help":"Describe progress level of damaged items at time of loss","type":"text","label":"How far had construction/ erection of the damaged item[s] progressed at the time of the occurrence of damage?","options":[],"required":null,"pdf_field":""},{"help":"State if any changes will be made during repairs","type":"text","label":"Any alterations or improvements be made to design, construction or material when repairs are carried out?","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated monetary loss","type":"amount","label":"What is the estimated amount of loss or Damage?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are existing buildings or surrounding property damaged due to construction / erection work and which caused a delay in completion of business?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are existing buildings or surrounding property damaged due to construction / erection work and which lead to any loss of profit?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Were there any seasonal events that would affect the completion and consequently affect the gross profit?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter sum insured for ALOP","type":"amount","label":"ALOP Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter indemnity period in months","type":"number","label":"Period of Indemnity in months","options":[],"required":null,"pdf_field":""},{"help":"Enter time excess in days","type":"number","label":"Time excess in days","options":[],"required":null,"pdf_field":""},{"help":"Estimate interruption period in days","type":"number","label":"Probable Interruption of period [in days]","options":[],"required":null,"pdf_field":""},{"help":"Provide monthly gross profit figures for first year","type":"text","label":"Anticipated gross profit for the first year of operation [monthly figures]","options":[],"required":null,"pdf_field":""},{"help":"Describe any penalty agreements related to contract","type":"text","label":"Details of any penalty agreements in connection with the contract work","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Loss Notification and Previous Repairs","fields":[{"help":"","type":"yes-no","label":"Whether loss intimated to Fire Brigade","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe previous repairs if any","type":"text","label":"Has the property undergone any repairs previously? If “Yes” What was the nature of such repairs?","options":[],"required":null,"pdf_field":""},{"help":"Enter last financial year's turnover","type":"amount","label":"What was the annual turn-over for the last financial year? Rs.","options":[],"required":null,"pdf_field":""},{"help":"Estimate turnover reduction due to interruption","type":"amount","label":"What is the estimated reduction in turn-over due to interruption Rs.","options":[],"required":null,"pdf_field":""},{"help":"Estimate gross profit loss due to interruption","type":"amount","label":"What is the estimated loss of Gross Profit due to interruption Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter expenses incurred to minimize loss","type":"amount","label":"Standing Charges/Expenses incurred for Loss Minimization, if any","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any responsible parties","type":"text","label":"Were there any person/organization, in your opinion, responsible for the loss? please provide details","options":[],"required":null,"pdf_field":""},{"help":"Describe preventive measures taken","type":"text","label":"What steps have been taken to prevent recurrence of similar incidence?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Other Insurance and Previous Losses","fields":[{"help":"List all other insurance policies covering the risk with details","type":"table","label":"Give details of insurance with any other insurance company on the risk involved [Please give following details pertaining to all the policies involved accident:] Name of Insurer Address/ Contact Details Policy No. Period Of Insurance Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"List previous losses in last 3 years with details","type":"table","label":"Details of Previous Losses during the 3 preceding years Date of loss Claim Description and Cause of Loss Estimated Loss Name of Insurer Claim Settled amount","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration and Signature","fields":[{"help":"Sign the form","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print name of insured or claimant","type":"text","label":"Name of Insured/Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"ECS Details of the Insured","fields":[{"help":"Enter bank account holder name","type":"text","label":"Name of the Insured (as appearing in the Bank Account)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch and address","type":"text","label":"Branch and address","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Specify account type (e.g. savings/current)","type":"text","label":"Bank Account Type","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code of bank branch","type":"text","label":"MICR Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The particulars furnished are true and correct to the best of my knowledge."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"nia.[office code]@newindia.co.in","label":"Email for Claim Intimation (replace [office code] with actual code)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/Customer%20Information%20Sheet%20%28CIS%29%20Two%20Wheeler%20Package%20Policy.pdf","quote":"laim to The New India Assurance Co Ltd via– • Website – www.newindia.co.in • Toll Free Number – 1800-209-1415 • Email – nia.[office code]@newindia.co.in • Details of procedure to be followed for cashless service as well as for reimbursement of claim • Intimation of claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-209-1415","label":"Toll Free Number for Claims Intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/Customer%20Information%20Sheet%20%28CIS%29%20Two%20Wheeler%20Package%20Policy.pdf","quote":"claimant may intimate claim to The New India Assurance Co Ltd via– • Website – www.newindia.co.in • Toll Free Number – 1800-209-1415 • Email – nia.[office code]@newindia.co.in • Details of procedure to be followed for cashless service as well as for re","fetched_at":"2026-10-20"}],"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/new-india-assurance/965-claim-form"}