THE NEW INDIA ASSURANCE COMPANY LIMITED

( Wholly owned by Govt. of India)

CLAIM FORM
INSURANCE CLAIM FORM (SHIELDSURE)
MOBILE HANDSET TABLET LAPTOP DIGITAL CAMERA CAMERA LENSES

IMPORTANT: PLEASE NOTE THE FOLLOWING CAREFULLY.

You can fill this form in English or Hindi. Please do not fill it in other language.
Please fill all the required information correctly and completely for easy processing of your claim.
Please do not leave any field unanswered, Leaving the field blank would lead in delay of Claim Process.
Please send all claim related documents completely filled and duly signed, within 15 days from the date and time of event
of loss.
All photocopies have to be self-attested by the insured.
In case of incomplete documentation your claim will not be processed.
All documents to be scanned & send it on claims@shieldsure.com
Please note that the issue of this claim form is not to be taken as an admission of liability.
Note: (*) mark field implies mandatory fields, need to be filled in detail compulsory or else the document shall be treated
as incomplete.

DETAILS OF INSURED/ BENEFICIARY

*Insurance Id *Claim Intimation No. *Intimation Date

*Name of The Customer / Purchaser:

(please write complete name including

father/mother/ spouse name etc. as applicable)

*Address of The Customer/ Purchaser:

*Pin:

*Contact Nos:

*Email Id:

DETAILS OF GADGET
*Name of The Retailer

*Make & Model

*Invoice No. (SHIELDSURE) *Invoice Date (SHIELDSURE)

* Invoice No.(GADGET) *Invoice Date (GADGET)

*SIM 1 IMEI No. *SIM2 IMEI No. *SR No. LAPTOP / TABLET *SR No. CAMERA/LENSES
 DETAILS OF LOSS:
Please enter relevant information according to the nature of your claim i.e. (Theft/Burglary/Damage)
*Date of Loss: DD/MM/YYYY *Time of Loss: H H M M
Is there any other
insurance cover
*Type of Loss: Theft Damage for this equipment,
if yes then please
provide entire
*Brief description of incident detail:
of loss:

(If space is insufficient use a

separate sheet & sheet &
attach)

TO BE FILLED IN CASE OF DAMAGE CLAIMS

*Type of Damage: *Service Centre:

* Repair Invoice Date: *Repair Invoice Amount:

TO BE FILLED IN CASE OF THEFT CLAIMS

*Reported Police Station address: *Police Reference No/ GD number: *Police Station Landline number:

* 10-digit Mobile Number used at the time of loss: Police Station Inspector Name & Designation:

*Type of SIM tariff (Prepaid/Postpaid connection): *SIM Network Provider:

*Letter for barring SIM service given to Network Provider(YES/NO): *If YES, please give date of
submission

Sr. No List of Documents to be attached with this Claim Form Tick

01. Self-attested Photocopy of Bill/ Invoice of Handset/ Equipment.
02. Self-attested Photocopy of Bill/ Invoice of SHIELDSURE Product.
03. Self-attested Photo ID proof of the insured.
Clear colored printouts of 03 photographs of equipment showing the damages and 01 showing
04.
IMEI no. on the Handset.
05. Original Invoice of Repair from Service Centre
06. Original Receipt/ Proof of Payment/ Credit card charge slip
Sim Blocking Letter or Email Copy from Service Provider (in case of Theft claim)
07.
(to be procured within 48 hours of the incident)
08. Original Police Complaint Letter/ FIR (in case of Theft claim)
(to be procured within 48 hours of the incident)
Letter from Authorized Service Centre confirming that the equipment is not repairable or is
09.
beyond economic repair.
Cancelled Cheque leaf with A/C No., IFSC code, MICR code & Name of the A/C Holder Printed
10.
on it.

DECLARATION
I/We agree to provide additional information to the company, if required. I/We the above mentioned, do hereby, to the best of my/our
knowledge & belief, warrant the truth of the foregoing statement in every respect & if I/We have made, or in any further declaration the
company may require in respect of the said loss, shall make any false or fraudulent statement, or any suppression or concealment, the
policy shall be void and all rights to recover there under in respect of reimbursement shall be forfeited.

DATED: Signature of Insured Person/ Beneficiary

PLACE: