Plate Glass Claim Form - Sbi General Page 2
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4WITNESS DETAILS
1. Were there any witnesses to the loss/accident?
Yes
No
If 'Yes',
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2. Name as Person/s
3. Address
Plot No/Door No.
Building Name
Road
Area
City
Pincode
State
4. Contact Details
Phone No.
Mobile
E-mail Id
INFORMATION TO AUTHORITY
1. Has the loss been reported to an Authority?
Yes
No
If 'No', reason for not reporting
If 'Yes', provide details
Fire
Police
Municipality
Other
2. Name of Authority
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Y
Y
Y
Y
3. Information Report No./
Date
Authority Reference No.
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4. Contact Person/s
5. Address
Plot No/Door No.
Building Name
Road
Area
City
Pincode
State
6. Contact Details
Phone No.
Mobile
E-mail Id
C. DETAILS OF OTHER INSURANCE
1. Is the loss / damage covered under any other Insurance?
Yes
No
If 'Yes', specify details and attach a copy of the policy
Name of Insurer
Address
Plot No/Door No.
Building Name
Road
Area
City
Pincode
State
Contact Details
Phone No.
Mobile
E-mail Id
Policy Number
Sum Insured
Period of Insurance
From
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To
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