(A Govt.

of India Undertaking)

SANGEETHA HANDSET INSURANCE CLAIM FORM

Master Policy No: 421701/48/2010/1481

Please note that the issue of this claim form is not to be taken as an admission of liability

DETAILS OF INSURED
1 Name: Sangeetha

1 Name of & Address of Customer:

2 Contact Number & Details of Claimant:

E-Mail Id:
DETAILS OF HANDSET
1 Make / Model of Handset:
2 Purchase Invoice No & Date:
3 Handset IMEI No:
DETAILS OF LOSS
1. Date & Time of accident
2. Brief description of accident
(If The space is insufficient use a
separate sheet)
3. Cause (Physical Damage/Water
Damage/Theft)
4. Value of loss
5 Has the matter been reported to police?

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 and belief, warrant the truth of the foregoing statement in every
respect, and if I/We have made, or in any further declaration the company may require in respect of the said
accident, 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 past or future accident shall be forfeited.

Date:

Place: Signature of insured Person

Attach a copy of Photo ID& Signature Proof
Dated: ___________

TO WHOMSOEVR IT MAY CONCERN

I Mr. / Ms _______________ would hereby like to inform that I had purchased mobile from
Sangeetha Mobile Stores vide Invoice No ________________ dated ____________, bearing
IMEI No. _________________________ Make ____________.

The said mobile is been stolen / damaged on _________________ while (Cause of Loss to be in
detail to be mentioned here).

Brief Description of Incidence:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________

I was using the service of ___________________ (Service Provider) and my mobile no. for
same was _______________________. I have already informed the service provider to bar the
services (incoming & outgoing, applicable only in the case of theft of mobile).

Further I would hereby like to also inform that police complaint has been lodge for loss of the
subject mobile; letter in effect of same is attached herewith.

In connection to the aforementioned loss, I would hereby like to assign, transfer my authority to
block the IMEI No. to Oriental Insurance Company Ltd, Divisional Office -7: Shankar House, 3rd
floor, No. 1, RMV Extn. Mekri Circle, Bangalore-80. I have no objection if Oriental Insurance Co.
Ltd raises a request to the manufacturer and gets the aforementioned IMEI No. blocked.

I have read all the above mentioned information and I accept the same in totality and same are
true to my knowledge.

Thanking you,

Signature & Address of the Insured:

 Date: ___________
To,
Police Station Incharge,
___________________
___________________
___________________

Reg: Lodging a complaint against mobile bearing IMEI No. ____________________

Dear Sir,

We would hereby like to inform you that my mobile purchased from Sangeetha Mobile Stores vide
Invoice No ________________ dated ____________, bearing IMEI No. _______________ has
been stolen on _________________.

Brief Description of Incidence:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

I was using the service of ______________ (Service Provider) and my mobile no. for same was
_______________________. I have already informed the service provider to bar the services
(incoming & outgoing) against the aforementioned no, letter in effect of same is attached herewith
for your ready reference.

We would hereby like to lodge a complaint for the stolen mobile and request you to kindly assist
us in finding the said mobile. As soon as the said mobile is recovered kindly inform to
Oriental Insurance Co. Ltd, Divisional Office: 7, Shankar House, 3rd floor, No1, RMV Extn., Mekri
Circle, Bengalure-80.

We would further request you to kindly let us know the reference no for our complaint; so that
same can be used in future.

Thanking you

Signature of the Insured Seal & Signature of Police Station

With Address:

Place: Place:
Date: Date:
 Date: ___________

To,
Customer Service Manager,
…………………………………
…………………………………
…………………………………

Reg: Barring Services to Mobile No: ______________________

Dear Sir,

This is to certify Mobile No: ____________ is in the name & address of

_____________________________________________________________________________
_____________________________________________________________________________.

We would hereby like to inform you that my mobile along with the SIM for the no
_______________________ has been lost on ____________.

Accordingly we would hereby request you to kindly bar the incoming and outgoing call of the said
number.

Please do the needful and bar the calls on receipt of the said letter.

Thanking you,

Signature & Address of Claimant, Seal & Signature of Service Provider,

Date: Date:

Place: Place: