If your Bajaj Allianz Policy covers fire losses then you may fill this form and submit it to the Bajaj Allianz Claim office along with the other required documents. Such as police complaint records, fire brigade intimation proofs etc. This form may only be used to claim the loss caused by fire if you have a valid Bajaj Allianz Policy which covers fire losses.
Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune – 411 006
FIRE CLAIM FORMFIRE CLAIM FORM
Claims No. :
(For Official Use)
Name of Insured
What was the nature of the occurrence and when did it take
At p.m. on a.m.
At what address did it take place?
For what purposes were the Premises being used at date of
Describe briefly what happened and the resultant damage,
and state what you believe caused it to happen
Were the Premises and their occupation at the time of the
occurrence exactly as described in the Policy ?
Had any element of risk been introduced which was not
allowed by the Policy ?
Is the Claimant the Sole Owner of the property damaged or
If not, state full particulars of any other Interest
7. Who has witnessed the loss?
Please enclose his statement.
8. What measures were taken to minimize the loss ?
9. If damage is due to the ‘Act of God’, then please enclose the
report from the meteorological department / newspaper
Describe the incident.
10. Has the Public Fire Brigade /Police were informed?
If yes, Please enclose the certificate from the Fire Brigade/
F.I.R from Police.
11. Give dates of any previous claims of a similar nature you
D D M M Y Y
13. Were there at the time of the occurrence any other existing
Insurance policies on the said Property, with any other
Company or Insurer, whether effected by the claimant or by
any other Person ?
If Yes, please provide full particulars
Details of Claim for property destroyed or damaged as required by the conditions of the company’s policies.
Policy No. &
Item of Policy
Description of property
claimed for in detail
Amt. Insured Market Value
at time of loss
after the loss
I/We do hereby solemnly and sincerely declare that the details appended hereto, are a full, true and correct statement of the loss, sustained
by me/us on the property insured by the above policy in consequence of the aforesaid loss amounting to the sum of Rs.________________ and
that the amounts claimed in respect of each and all of the several articles or items of property damaged or destroyed, constitute their value at the
time of loss or damage not including profit of any kind.
I/We do hereby solemnly and sincerely declare that I/We have not either directly or indirectly, proximately or remotely caused the said loss,
or by connivance, fraud or misrepresentation sought to benefit thereby, and I/We make the foregoing solemn declarations conscientiously
believing the same to be true, this____________ day of___________________
Signature of the Insured