{"id":977,"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/fire/industrial-all-risk/Claim%20Form.pdf","sha256":"912d9b9379398c4a24ad3b3abdf1d70f7fa8fef870a1b9b99b02442e967f4617","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder to file a claim for loss or damage 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 Contact 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","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"Describe your business or occupation briefly","type":"text","label":"Brief Description of Business/Industry/Occupation","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"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":"Address where loss occurred","type":"text","label":"Loss Location Address","options":[],"required":null,"pdf_field":""},{"help":"Describe how the loss happened","type":"text","label":"Nature and Cause of Loss (Please describe the circumstances leading to the loss)","options":[],"required":null,"pdf_field":""},{"help":"Provide Name of Insurer, Address/Contact Details, Policy No., Period of Insurance, Sum Insured","type":"table","label":"Give details of insurance with any other insurance company on the risk involved in fire/accident","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Previous Claims and Witness Details","fields":[{"help":"","type":"yes-no","label":"Was any claim reported in the past on the same property during current policy period?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of previous claims if any","type":"table","label":"Cause of loss Date of incident Policy Issuing Office Details of loss Amount of claim paid / Outstanding","options":[],"required":null,"pdf_field":""},{"help":"Provide witness contact details","type":"text","label":"Details of the witness to the occurrence Name Address Mobile No. Email Id","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Ownership and Notification Details","fields":[{"help":"Describe ownership interest and provide contact details","type":"text","label":"If insured is not sole owner the nature of his/their interest in the property Mobile No Email Id","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss was reported to authorities","type":"text","label":"Whether loss intimated to Police / Other appropriate legal Authorities Fire Brigade","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Policy Details Related to Fire/Accident","fields":[{"help":"Provide details of all policies related to the fire/accident","type":"table","label":"Please give following details pertaining to all the policies involved in fire accident: Policy No Risk Covered Location Sum Insured Estimated amount of Loss","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Item Affected","fields":[{"help":"Provide detailed information about each affected item","type":"table","label":"Details of Item affected Sl. No. Description of Equipment / Inventory. Brand New or Second Hand Manufacturer Type of Machine output / capacity Year of Manufacturing Identification Machine / Serial No. Sum Insured {Rs.} Date of last maintenance Date of Expiry of AMC/ Warrantee Cost of repair / Replacement","options":[],"required":null,"pdf_field":""},{"help":"Provide date or details of last maintenance","type":"text","label":"What was the last occasion before the damage when the machine was over hauled or attended to for maintenance or damage","options":[],"required":null,"pdf_field":""},{"help":"Estimate the financial loss","type":"amount","label":"What is the estimated amount of loss or Damage?","options":[],"required":null,"pdf_field":""},{"help":"Describe cause and circumstances of damage in detail","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":"Provide details of any previous repairs","type":"table","label":"Has the property undergone any repairs previously? If “Yes” What was the nature of such repairs? Date of Repair Nature of Repair Parts affected Cost of Repair [Rs.]","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Consequential Loss","fields":[{"help":"Indicate if business nature changed after policy start","type":"yes-no","label":"(i) Whether any alteration has been made in the nature of business/occupation of premises after inception of Policy? If 'Yes', please give details","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if premises were occupied during loss","type":"yes-no","label":"(ii) Were the premises occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide date and reason for un-occupancy and damage details","type":"text","label":"(iii) If 'No', un-occupied since (date) for (specify reason/s) Details of Damage under Material Damage Section under IAR Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated loss amounts for each category","type":"table","label":"Estimated Loss Material Damage (Rs.) Building P & M FFF Stocks Other 1 Other 2","options":[],"required":null,"pdf_field":""},{"help":"Specify duration of business interruption","type":"text","label":"Period for which the business was interrupted due to Fire and Special Perils/MBD","options":[],"required":null,"pdf_field":""},{"help":"Enter last year's annual turnover","type":"amount","label":"(i) What was the annual turn-over for the last financial year? Rs.","options":[],"required":null,"pdf_field":""},{"help":"Estimate turnover loss due to interruption","type":"amount","label":"(ii) What is the estimated reduction in turn-over due to interruption Rs.","options":[],"required":null,"pdf_field":""},{"help":"Estimate gross profit loss","type":"amount","label":"(iii) What is the estimated loss of Gross Profit due to interruption Rs.","options":[],"required":null,"pdf_field":""},{"help":"Provide expenses incurred to minimize loss","type":"amount","label":"(iv) Standing Charges/Expenses incurred for Loss Minimization, if any","options":[],"required":null,"pdf_field":""},{"help":"Provide details if anyone is responsible","type":"text","label":"(v) 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":"(vi) What steps have been taken to prevent recurrence of similar incidence?","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Previous Losses","fields":[{"help":"Provide details of losses in last 3 years","type":"table","label":"Losses during the 3 preceding years Date of Loss Claim Description and Cause of Loss Value of Loss (Rs.) Insurer","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Information","fields":[{"help":"Use additional pages if needed","type":"text","label":"Do you wish to provide any other information?","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"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 full name","type":"text","label":"Name of Insured/Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"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 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","type":"text","label":"MICR Code","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The undersigned policyholder declares to have answered the above questions conscientiously and faithfully.","The policyholder is liable for the correctness and completeness of his statement."],"dropped_labels":0},"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/977-claim-form"}