Plate Glass Claim Form - Sbi General

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SBI General Insurance Company Limited
Call (Toll Free)
1800 22 1111 | 1800 102 1111
PLATE GLASS INSURANCE POLICY
Claim Form
Issue of this Claim Form is not to be taken as an admission of liability. If any detail or information is not readily available please do not delay the dispatch of
this form and such particulars may be sent later.
Policy No.
Claim No.
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Period of Insurance From
To
A. DETAILS OF INSURED/CLAIMANT
1. Name as per Policy
2. Address
Plot No/Door No.
Building Name
Road
Area
City
Pincode
State
3. Contact Details
Phone No.
Mobile
E-mail Id
4. Brief Description of Business/
Office/Industry/Occupation
5. Limits of Indemnity under
the Policy (Rs.)
B. DETAILS OF LOSS/ACCIDENT
1. Date of Loss
Time of Loss
:
A.M. / P .M.
D
D
M
M
Y
Y
Y
Y
2.
Loss Location
Address
Plot No/Door No.
Building Name
Road
Area
City
Pincode
State
3.
Contact Details of person/s at Loss Location
Name
Relationship with Insured
Contact Details
Phone No.
Mobile
E-mail Id
4. Describe cause of
Loss/Damage
5. Estimated Loss (Rs.)
1
Corporate & Registered Office: ‘Natraj’, 101, 201 & 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai - 400 069.

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