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Claim Form

This document appears to be a claim form for a fraudulent or lost credit card from The New India Assurance Co. It requests basic details about the customer, their account, and the disputed transaction. It asks for information like the date and time of the incident, brief details of what happened, when the card was blocked, if a police report was filed, and bank details for claim settlement. Additionally, it requests details to verify the customer's identity and address and seeks the investigation team's recommendation on whether fraud occurred along with any other helpful details to process the claim.

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nishit
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
171 views2 pages

Claim Form

This document appears to be a claim form for a fraudulent or lost credit card from The New India Assurance Co. It requests basic details about the customer, their account, and the disputed transaction. It asks for information like the date and time of the incident, brief details of what happened, when the card was blocked, if a police report was filed, and bank details for claim settlement. Additionally, it requests details to verify the customer's identity and address and seeks the investigation team's recommendation on whether fraud occurred along with any other helpful details to process the claim.

Uploaded by

nishit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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The New India Assurance Co.

Ltd
LCBO-990000, New India Centre, Ground Floor,
17/A Cooperage Road, Mumbai- 400 039
Claim Form for Fraudulent/Lost Card Liability

Basic Details
1. Claim No
2. Customer Name
3. Account no
4. Card no
5. Customer’s relation with the Bank in terms of Years
6. Card Type
7. Date and Time of Accident
8. Place of Accident

9. Brief details of incident of Fraud

10. Claim Amount


11. Date and Time of Request for Hot Listing
12. Date and Time of Card blocking
13. No of card issued in account
14. Misuse card issue date
15. Maximum Limit of Insurance Provided
16. Daily Withdrawl Limit
17. Who blocked the card ?
18. Did Customer received any SMS alert for the disputed txn
?
19. At the time of disputed txn took place, whether card was
with Customer ?
20. How did the Customer realized about the misuse of card
and on which date?
21. Is there any delay in blocking the card? If Yes, Specify
Reason
22. Is the card in possession with Customer ?
23. Where Customer used his card last time ?
24. Did Customer used his card abroad?
25. Confirm with Customer where he was at the time of
disputed txn?
26. Is there any ATM transaction in dispute?
27. Is Police complaint lodged? If Yes, Date of police
complaint
28. Date of Filing for Chargeback
29. Date of Rejection of Chargeback
30. Bank Details ( For Claim Settlement) Name:
Bank Name:
A/c No:
IFSC Code:
Branch Name:

Customer Profile
Occupation( if salaried or self employed please mention the
name of the organisation)

Designation

Is there any difference in addresses mentioned in system and


actual address ( for future communication)

Additional comments, if any


Investigation Analytics Team Recommendation
Confirm Fraud?

Any other information helpful in processing the claim

All details are verified from us. Here we confirm that there is no involvement of any bank official/staff in
this fraudulent act and this is done fully by cloned card and original card is destroyed in front of me.

Name

Designation

Employee No. Signature with seal of Bank official


(to be provided on all pages)

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