Plate Glass Claim Form - Sbi General Page 4
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4DECLARATION
I/We, the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect; and I/We
agree that if I/We have made, or make in any further declaration, the Company may require in respect of the said accident, any false or fraudulent
statement, or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and void, and all rights to recover there
under in respect of past or future loss/accident shall be forfeited.
Place
Signature of
Insured/Claimant
D
D
M
M
Y
Y
Y
Y
Date:
Name of Insured/Claimant
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