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    Claim Form For Cattle - Fina1

    Uploaded by

    Moin Jahangiri
    This document is a cattle insurance claim form. It requests details about the insured, descriptions of the cattle, and circumstances of the claim including the nature of illness or injury, treatment details, and estimates of value. The form notes that submission does not imply admission of liability and requires declaration of truthfulness of the claims.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Claim Form For Cattle - Fina1

    Uploaded by

    Moin Jahangiri
    38 views2 pages
    This document is a cattle insurance claim form. It requests details about the insured, descriptions of the cattle, and circumstances of the claim including the nature of illness or injury, treatment details, and estimates of value. The form notes that submission does not imply admission of liability and requires declaration of truthfulness of the claims.

    Original Description:

    desa

    Original Title

    Claim Form for Cattle - fina1

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    This document is a cattle insurance claim form. It requests details about the insured, descriptions of the cattle, and circumstances of the claim including the nature of illness or injury, treatment details, and estimates of value. The form notes that submission does not imply admission of liability and requires declaration of truthfulness of the claims.

    Copyright:

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

    Claim Form For Cattle - Fina1

    Uploaded by

    Moin Jahangiri
    This document is a cattle insurance claim form. It requests details about the insured, descriptions of the cattle, and circumstances of the claim including the nature of illness or injury, treatment details, and estimates of value. The form notes that submission does not imply admission of liability and requires declaration of truthfulness of the claims.

    Copyright:

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

    Bajaj Allianz General Insurance Co. Ltd.

    Claim Form

    PLEASE ANSWER EVERY QUESTION AND FULLY


    The issue or acceptance of this form is not to be construed as admission of liability on the part of
    the Company
    Regional/Branch Office Code
    Broker/Agent Name & code Code

    Insured Details
    1. Name of the Insured

    2. Address of the Insured Plot No/Door Building name


    No.
    Road
    Village
    City Pin code
    State
    Phone No.

    Details of Cattle in respect of which claim is made


    Type of Sex Age Breed Description of the Cattle Identifi Insured’s
    Cattle cation estimate
    Details Tag of Market
    of the No. Value.
    Cattle M/F Years Colour Horns Tail Distinguishing Rt/Lt Rs.
    Switch Features Ear

    Details of the Claim- Cover 1


    1. Nature of Disease contracted.
    2. Date Disease was first detected
    3. Details regarding treatment of
    Disease.
    4. Name of Vet attending and Performing
    Post-mortem
    5. a) Date of the Death

    b) Cause of Death

    c) How and where did the accident


    happen?
    Details of the Claim- Cover 2
    6. a) Nature of Permanent Total
    Disability
    b) Certificate from Vet obtained? If
    yes, please attach.

    6. Name & address of the Vet who issued


    the Certificate of Soundness

    7. Name & address of the Hospital where


    treatment is taken/being taken

    8. Do you have any other Cattle


    Insurance Policy? If Yes, give details.

    I/We hereby declare that the foregoing statements are true in all respects and that I/We have not
    attempted to conceal from the company anything with which it ought to be made acquainted. I/We
    confirm my/our understanding that if I/we have made or will make in any further declaration the
    Company may require any false or fraudulent statement or suppression or conceal any material fact
    or advance any untrue fact whatever, the Policy shall be void and my/our right to compensation
    forfeited and I am/ we are willing if required, to make a statutory Declaration before a Justice of the
    Peace of the truth of the whole of the foregoing statement or any other statement I/We may make in
    connection with this claim.

    Signature of the Insured


    Date ……………………………..
    Address …………………………. Date
    ………………………………..

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