Lost Card Liability/Skimming/Counterfeit/ATM Transaction Form
(The issue of this form is not to be taken as an admission of liability)
Details of Insured
Insured Name/Bank Name
Address:
Claim Ref No : If (available) SEX (M/F)
Cardholder Name
Disputed Card Number 1 (Only First & last 4 card digits) X X X X X X X X
Disputed Card Number 2 (Only First & last 4 card digits) X X X X X X X X
Disputed Card Number 3 (Only First & last 4 card digits) X X X X X X X X
Disputed Card Number 4 (Only First & last 4 card digits) X X X X X X X X
Validity Period
Date of Card Issuance
Date and time of Loss
Type of Loss (with brief details)
Date & time of reporting/intimation to the Bank
Date & time of Blocking the Card
Copy of Card Statement
Dispute letter from Card holder
Loss location (City and Country)
Date of Birth of Cardholder
Corporate Name (If applicable)
Insured Person’s Address at the time of loss
Insured Person’s permanent address
Loss Amount
Type of Transaction (Please tick)
A) ATM Transaction
B) Point of sale (merchant establishment )
C) Internet Transaction
IRDAIReg No. 146.
HDFC ERGO General Insurance Company Limited
Merchant establishment details : (where disputed
transaction took place)
1) Name
2) Contact No
3) Address
4) Email ID
Date and time of reporting the loss to Police
station. (Please furnish copy of FIR)
Name and Address of the Police station
Are you the sole owner of the property?
Have you ever before sustained loss of the same
nature? If so, give particulars
Is there any other insurance on the same
property? If so, give full particular
Any additional information relevant to
processing the claim
I/we hereby agree, affirm and declare that:
a) The statement/information given/stated by me/us in this claim form is true and complete.
b) The details of all persons having an interest in the property in respect of which the claim is
being made are provided as per the proposal form or by way of an endorsement in the policy.
Furthermore, save and except as provided or disclosed in this claim form, no claim made
hereunder (or the same/similar claim) has been made or lodged with any other insurance
company.
c) No material information which is relevant to the processing of the claim or which in any
manner has a bearing on the claim has been withheld or not disclosed.
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13,2016).
CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai – 400020.
Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai – 400 059.
Tel.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | [email protected] | www.hdfcergo.com. IRDAIReg No. 146.
HDFC ERGO General Insurance Company Limited
d) If I/we have given/made any false or fraudulent statement/information. or suppressed or
concealed or in any manner failed to disclose material information, the policy shall be void and
that I/We shall not be entitled to all/any rights to recover there under in respect of any or all
claims, past, present or future.
e)The receipt of this claim form/other supporting/related documents does not constitute or be
deemed to constitute an agreement by the Company of the claim and the Company reserve the
right to process or reject or require further/additional information in respect of the claim.
Date -:
Place: Signature of Cardholder/Bank officer
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13,2016).
CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai – 400020.
Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai – 400 059.
Tel.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | [email protected] | www.hdfcergo.com. IRDAIReg No. 146.
