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Ssion of liability. If any detail or information Is not readily available please do not delay the dispatch of this form and such particulars may be sent later. Policy No. Period of Insurance From Claim No. D D M M Y Y Y Y To D D M M Y Y Y Y A. DETAILS OF INSURED/CLAIMANT 1. Name as per Policy 2. Address Plot No/Door No. Building Name Road Area City Pincode State 3. Contact Details Phone No. Mobile E-mail Id 5. Limits of Indemnity under the Policy (Rs.) Sum Insured.

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