This Bajaj Allianz Fedelity Guarantee policy pays for the financial loss sustained as a result of the dishonesty / fraudulent act of an employee. The loss is payable up to the limit specified for an employee according to the policy guidelines. This policy does not pay more than one claim in respect of liability/loss arising out of an individual employee’s acts. Fill out and submit the Claim form to the Bajaj Allianz claim office for proceedings.
Bajaj Allianz General Insurance Company Limite.
Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune – 411 006.FIDELITY GUARANTEE INSURANCE CLAIM FORM
The issue of this form does not constitute admission of liability. Please return the form duly completed within Fourteen days of the loss together with th.
relevant vouchers, documents etc.
Policy No
Claim No. ______________________.
Date of registration ______________________.
Regional/Branch Office Code _________________________.
Broker/Agent Name ______________________________________________________________________________ Code________________.
1..
Name of the Insure.2. Customer
I.
________________________.
3. Address of the InsuredPhone No.E-mail Id ___________________________________________
4. a.
Name of the defaulting employee in ful.b).
His/her present address.5..
Amount of loss sustaine.
Rs. _____________________.
6..
Date of discovery of the defalcatio.
________________________.
7..
Date (s) of defalcation (s.
________________________.
8..
How exactly was the defalcation committed?.
_________________________________________________________________________.
If space is not sufficient, please give full and detailed particulars on a separate signed sheet. Also please attach a certified statement containing al.
entries in your books of accounts relative to the defalcation in the order of their dates.
9..
Please reply fully to the following questions regarding the duties of the employee at the time of defalcation :.
a.
In what capacity was he engaged and where? _______________________________________________________________________.
Mone.
b.
In what way did money reach his hands? __________________________________________________________________________.
c).
What was the largest sum which he had in his hands at any one time and for how long? _______________________________________.
d).
Was he allowed to pay out any amounts on your behalf? ______________________________________________________________.
e).
Who authorized these payment or issue? __________________________________________________________________________.
f).
Was he required to give printed receipts from a book with counterfoils? ____________________________________________________.
If so, how often were the counterfoils examined and checked and by whom.
g).
Did the defaulting employee pay money into the Bank? _______________________________________________________________.If so, how often were Bank Books examined and checked and by whom? ___________________________________________________.
h).
What balance, if any was allowed to be kept in his hand? ______________________________________________________________.
i).
How often is Cash Accounts balances and how was their accuracy checked? ________________________________________________.
Please explain fully __________________________________________________________________________________________.
j).
How often were accounts sent direct to Customers independently of the employee? ___________________________________________.
Stoc.
k).
Did the employee have charge of stock? ___________________________________________________________________________.
If so, in what way did stock reach his hands? _______________________________________________________________________.
l).
Was he allowed to issue stores or materials independently? ____________________________________________________________.
If not, who authorised these issues? ______________________________________________________________________________.
m).
How often was the position of stock handled by the employee checked? ____________________________________________________.
n).
When was the last check made? ________________________________________________________________________________.
10..
How often were the Account Books/Stock Books at the place of the defaulting employee’s employment audited and by whom? _________________.
When was the last audit done? ____________________________________________________________________________________.
11..
Have you any money, estate, or effects of the employee in your possession? ___________________________________________________.
If so, give particulars with amounts. _________________________________________________________________________________.
12..
Do you hold any other security from the employee? _____________________________________________________________________.
If so, state its nature and amount. __________________________________________________________________________________.
13..
Is the defaulting employee a member of a joint family, or does he hold any property furniture or other effects? _________________________.
If so, give details._______________________________________________________________________________________________.
14..
Does the employee have any near relatives? ___________________________________________________________________________.
If so, give their names and addresses, if known._________________________________________________________________________.
15..
Have you taken any action against the employee? _______________________________________________________________________.
If so, state the nature of action taken.________________________________________________________________________________.
16..
Has the loss been reported to the Police? _____________________________________________________________________________.
If so, state at which Police Station and what action, if any has been taken by them.________________________________________________.
___________________________________________________________________________________________________________.
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 agre.
that if I/we have made, or, in any further declaration the Company may require in respect of the said occurrence shall make any false or fraudulent statemen.
or any suppression, concealment or untrue averment whatever, the Policy shall be void and my/our right to compensation forfeited.
Signature of Insured.
Place: __________________.
Date: __________________.
Witnes.
Signature __________________.
Name_____________________________________________________________________________________________________________.
Address ___________________________________________________________________________________________________________.
Date: __________________.