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    National Insurp. Nce Company Ijimited: Engineering Insurance Machinery Breakdown Claim Form

    Uploaded by

    Sadasivuni007
    This document is an engineering insurance machinery breakdown claim form from National Insurance Company Limited. It requests information about a machinery breakdown claim, including: [1] a description and value of the damaged machine(s); [2] when the loss or damage occurred; [3] details of the damage sustained; and [4] how the loss occurred and the probable cause. It also asks whether the machine's manufacturer's guarantee has expired, details of any repairs, and information about other relevant insurances.

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    © All Rights Reserved
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    National Insurp. Nce Company Ijimited: Engineering Insurance Machinery Breakdown Claim Form

    Uploaded by

    Sadasivuni007
    191 views2 pages
    This document is an engineering insurance machinery breakdown claim form from National Insurance Company Limited. It requests information about a machinery breakdown claim, including: [1] a description and value of the damaged machine(s); [2] when the loss or damage occurred; [3] details of the damage sustained; and [4] how the loss occurred and the probable cause. It also asks whether the machine's manufacturer's guarantee has expired, details of any repairs, and information about other relevant insurances.

    Original Title

    MBD Claimform

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    This document is an engineering insurance machinery breakdown claim form from National Insurance Company Limited. It requests information about a machinery breakdown claim, including: [1] a description and value of the damaged machine(s); [2] when the loss or damage occurred; [3] details of the damage sustained; and [4] how the loss occurred and the probable cause. It also asks whether the machine's manufacturer's guarantee has expired, details of any repairs, and information about other relevant insurances.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    191 views2 pages

    National Insurp. Nce Company Ijimited: Engineering Insurance Machinery Breakdown Claim Form

    Uploaded by

    Sadasivuni007
    This document is an engineering insurance machinery breakdown claim form from National Insurance Company Limited. It requests information about a machinery breakdown claim, including: [1] a description and value of the damaged machine(s); [2] when the loss or damage occurred; [3] details of the damage sustained; and [4] how the loss occurred and the probable cause. It also asks whether the machine's manufacturer's guarantee has expired, details of any repairs, and information about other relevant insurances.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ~ ~ih~ cw:rYfT ~ft{~iS

    NATIONAL INSURP.~NCE COMPANY IJIMITED


    ( A Subsidiary of Generflll'lsurflnce Corporation of India)
    ( Regd. Office: 3, MIDDLETON STREET. CALCUTTA-700 071

    ISSUING OFFICE:

    ENGINEERING INSURANCE
    MACHINERY BREAKDOWN CLAIM FORM

    Name of Insured _ _•............. _ ................................•...........•••••... Pol~cy NO : _ ....•....•...•.......

    Works Address _ _ _ ................•...•••..... C Iaim No ........................•...•.......•.•.•...•...•...•.......

    1. (a) Give full description and value of Machine(s)


    damaged

    (b) State the serial number(s) of the Policy


    Schedule

    2. When did the loss or damage occur?


    (State date and exact time)

    3. Give ~)articulars of damage sustained

    -------------.-.-------- -------.---
    4. How did the loss or damage occur and '",hat
    was its probable cause?

    5. Has the Manufacture's guarartee"period for the


    damaged Machine (5) expired? If so when?

    6. In What place and for what purposes was the


    machinery being use.d ot the time of tile
    hfC:ilkdown ?

    (P.T.O.)
    · ..
    7. -State what repairs 01' replacements are required
    and the estimafed cost thereof

    8. Have the repairs been put in hand?


    If so, give name and address of repairer (s)

    9. When can the damaged item(s) be inspected 7


    Note Dal"Qaged parts must be preserved pending
    Inspection by the Company's representative

    1 O. Are there any other insurances effected by you or


    any other person covering the loss sustained or
    any part thereof? If so, please give details.

    11. Other remarks. if any

    12. Particulars of ::nemium paid

    Amount:

    Date:

    I/we declare that the foregoing particulars are true and correct to the best of my/our knowledge.

    S ig!1 atu re_ ........••.. _._ _ _M .•.. _ •••..••••

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