Dear Customer,

We regret for the loss incurred by you.

Request you to kindly share the following details so that we can help you in loss settlement.

* Name of Policy Holder (required)

* Policy Number (required)

* Concerned Person Name (required)

* Concerned Person Contact Number (required)

* Concerned Person Email ID (required)

* Date of Loss (required)

* Cause of Loss

* Extent of Loss