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Claim Form For CPP PDF

The document is an insurance claim form for an All Risk policy covering a lost or damaged mobile phone. It requests details about the insured, the nature and circumstances of the loss or damage, and a declaration acknowledging the accuracy of the information and that any false statements would void the policy. The form collects information needed to process an insurance claim such as the device details, date of loss, description of the incident, and estimated value of damaged items.

Uploaded by

Vaibhav Pachaulee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2K views2 pages

Claim Form For CPP PDF

The document is an insurance claim form for an All Risk policy covering a lost or damaged mobile phone. It requests details about the insured, the nature and circumstances of the loss or damage, and a declaration acknowledging the accuracy of the information and that any false statements would void the policy. The form collects information needed to process an insurance claim such as the device details, date of loss, description of the incident, and estimated value of damaged items.

Uploaded by

Vaibhav Pachaulee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Aapka Plan B

CLAIM FORM FOR ALL RISK INSURANCE FOR CPP


Notification of Physical Loss or Damage
(The issue of this form is not to be taken as an Admission of Liability)

PLEASE ANSWER ALL QUESTIONS FULLY


1. POLICY DETAILS
(i) Insured Name
(ii) Policy No
(iii) Policy Certificate No
(iv) ILGIC Claim No
(V) CPP Claim No
2. DETAILS OF USER
(i) Name of the user
(ii) User (E mail) ID
(ii) User Contact Number
3. NATURE OF LOSS/ DAMAGE/ THEFT
Company :
Model No :
(i) Details of damaged/ lost Mobile
IEMI No :
Purchase Date :
(ii) Date and time of damage/ theft
Place & address where the loss/ damage/ theft
(iii)
took place
In case of theft, when and where was the missing
(iv)
property last seen? (applicable for theft cases)
Description of the event/ incident of theft/
damage (how the loss took place / came into
(v)
notice)

Estimated value of items damaged (not


(vi)
applicable for theft cases)
For theft cases, date and time of reporting
the loss to Police Station with name and
4. address of the Police Station.
Note : Please furnish copy of FIR/ stamped
copy of police intimation

Any additional information relevant to


5.
processing of claim
I/We hereby agree, affirm and declare that:

(a) The statements/information given/stated by me/us in this claim form are


true, correct and complete.

(b) The details of all persons having an interest in the property in respect of
which the claim is being made are provided as per the proposal form or by
way of an endorsement in the policy. Furthermore, save and except as
provided or disclosed in this claim form, no claim made hereunder (or the
same/similar claim) has been made or lodged with any other insurance
company.

(c) No material information which is relevant to the processing of the claim or


which in any manner has a bearing on the claim has been withheld or not
disclosed.

(d) If I/we have given/made any false or fraudulent statement/information, or


suppressed or concealed or in manner failed to disclose material
information, the policy shall be void and that I/We shall not be entitled to
all/any rights to recover thereunder in respect of any or all claims, past,
present or future.

(e) The receipt of this claim form/other supporting/related documents does


not constitute or be deemed to constitute an agreement by the Company of
the claim and the Company reserves the right to process or reject or require
further/additional information in respect of the claim.

Date:

Place: Signature of the Insured

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