{"id":995,"title":"BURGLARY CLAIM FORM","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/BURGLARY_and_HOUSEBREAKING_INSURANCE_POLICY_Business_Premises_56f1559563.pdf","sha256":"bcecee497a4d1445a49786edeefa0a942d7678061eaf928fb8c7337c399161c4","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim for loss or damage due to burglary or housebreaking at their insured business premises.","notes":[],"title":"BURGLARY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured and Loss Details","fields":[{"help":"","type":"text","label":"Insured’s Name and Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation/Business Address","options":[],"required":null,"pdf_field":""},{"help":"Specify the type of premises and exact location","type":"text","label":"Address of the premises at which the loss occurred (State whether private house, sale shop, flat, hotel etc. Outbuilding thereof)","options":[],"required":null,"pdf_field":""},{"help":"Provide the exact date and time when the loss occurred","type":"date","label":"a) Date and Time of loss","options":[],"required":null,"pdf_field":""},{"help":"State when the loss was discovered and the person who discovered it","type":"text","label":"b) When discovered and by whom","options":[],"required":null,"pdf_field":""},{"help":"Describe how entry was gained and if force was used","type":"text","label":"a) How was entry to the premises effected? Was force used.","options":[],"required":null,"pdf_field":""},{"help":"Describe the area entered and details of the loss","type":"text","label":"b) Which portion of the premises was entered? (Give brief details of how exactly the loss occurred, also specifying overleaf the articles stolen and property if any, damaged)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"a) Have the police been notified?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of the person who notified police, date and police station","type":"text","label":"b) If so by whom & when and at what Police Station","options":[],"required":null,"pdf_field":""},{"help":"Explain why police were not notified if applicable","type":"text","label":"c) If not state the reason for omission","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"a) Were the premises occupied at the Time of the loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide last date and time premises were occupied if not occupied at loss time","type":"text","label":"b) If not on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"State duration premises have been unoccupied","type":"text","label":"c) For how long have the premises been unoccupied since the policy was effected or last renewed?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"a) Is any body suspected of the theft?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of any suspects","type":"text","label":"b) If so please state full details.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"If there is no evidence of theft or of forcible entry of the premises has a thorough search been made for the articles missing","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"State ownership status of property and premises","type":"text","label":"a) Are you the sole owner of i) the property lost or damaged? ii) Of the premises?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"b) Are you responsible for repairs to premises?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of any previous similar losses","type":"text","label":"Have you ever before sustained loss by burglary, housebreaking or theft? (if so, please state particulars)","options":[],"required":null,"pdf_field":""},{"help":"Provide total value of all property at loss time","type":"amount","label":"a) State the total value of property upon the premises at the time of the loss","options":[],"required":null,"pdf_field":""},{"help":"Provide fire insurance amount and insurer names if any","type":"text","label":"b) State the amount of Fire Insurance upon such property and name of Company or Companies","options":[],"required":null,"pdf_field":""},{"help":"Mention any other insurance policies covering this loss","type":"text","label":"Are you insure against the present loss under any other Policy e.g. All Risks Passengers’ Baggage, Motor Car Golfers etc.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Details of Stolen or Damaged Articles","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Insured Signature…………….","options":[],"required":true,"pdf_field":""},{"help":"List each stolen or damaged item with ownership, purchase details, cost, depreciation, and net claim amount","type":"table","label":"Full description of articles stolen or property damaged, To whom the articles or property belonged, To whom purchased or received, Name and Address, Date of Purchased or received, Cost, Deduction for depreciation and wear and tear, Total, Deduction for Depreciation and wear & Tear, Net Amount Claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Burglary and housebreaking insurance claims for business premises","attachments":[],"declarations":["All statements made on this form are true to the best of my knowledge and belief.","The articles and property described belong to the persons named and no other person has any interest therein.","Claims must be based upon the actual value of the articles at the time of the theft, allowing for depreciation and wear."],"dropped_labels":0},"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/oriental-insurance/995-burglary-claim-form"}