Branch Office : 1/1, Connaught Road, Queens Road Cross, Bangalore Ph : ; FAX : MOBILE HANDSET INSURANCE CLAIM FORM

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1 Branch Office : 1/1, Connaught Road, Queens Road Cross, Bangalore Ph : ; FAX : MOBILE HANDSET INSURANCE CLAIM FORM PAI INTERNATIONAL MASTER POLICY NO /48/2016/1759 or /48/2015/695 Please note that the issue of this claim form is not to be taken as an admission of liability DETAILS OF INSURED 1 Name of the Retailer : PAI INTERNATIONAL ELECTRONICS LTD 2 Name of & Address of Customer: 3 DATE OF BIRTH Contact No and id 1 Make and model of handset: 2 Purchase Invoice No & DETAILS OF HANDSET 3 Handset IMEI No: DETAILS OF LOSS 1. Date, Time & place of incident 2. Brief description of incident (If space is insufficient use a separate sheet) 3. Estimated loss 4. Name & Address of Police Station alongwith Complaint/GD/CR/FIR No. 5. Do you have any other insurance on the said Mobile Handset? If so, please furnish particulars viz, Name of Insurance Company, Policy No., Period of Insurance 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. Signature of insured Person IMPORTANT : KINDLY ATTACH PROOF OF PHOTO IDENTIFICATION, DATE OF BIRTH AND A COPY OF SPECIMAN SIGNATURE PROOF.

2 LETTER OF SUBROGATION I Mr. / Ms would hereby like to inform that I had purchased a mobile vide Invoice No dated, bearing IMEI No. Make. The said mobile has been stolen on ( mention date) Brief Description of Incidence : I was using the service of Service Provider (please mention service provider like airtel, bsnl etc) and my mobile number for same was (please mention Mobile No.). I have already informed the service provider to terminate the services (incoming & outgoing) Further I hereby also confirm that police complaint has been lodged for theft of the subject mobile and a copy of the letter for the same is attached herewith. In respect of the subject loss, I hereby agree to transfer all my rights, remedies in respect of the above said Mobile to THE ORIENTAL INSURANCE CO LTD, BANGALORE I hereby declare that all information/details furnished herein are true to the best of my knowledge. Thanking you, SIGNATURE OF INSURED PERSON ADDRESS CONTACT NO.

3 (FORMAT OF POLICE COMPLAINT) To Police Station In-charge Reg: Request for registering Complaint - Mobile IMEI No. Make - Model - Dear Sir, I regret to inform you that my above mentioned Mobile Phone purchased vide Invoice No dated, bearing IMEI No. has been stolen on.(please mention date of incident) Brief Description of Incidence:. I was having PRE-PAID / POST-PAID facility and was using the services of Service Provider (please mention service provider like Vodafone, Airtel, BSNL etc) and my mobile number for same was (please mention Mobile No.). I have already informed the service provider to terminate the services (incoming & outgoing) Please register a complaint for the above mentioned stolen mobile and assist us in tracing the same at the earliest. As soon as the said mobile is recovered, kindly inform to THE ORIENTAL INSURANCE CO LTD, BANGALORE, with whom I have filed an insurance claim. Thanking you Signature of the Insured Address: Seal & Signature of Police Station

4 (FORMAT FOR SIM BLOCK CONFIRMATION TO BE CERTIFIED BY SERVICE PROVIDER) Customer Service Manager Date :. Reg: Barring Services to Mobile No: (PRE-PAID /POST PAID) Dear Sir, I wish to inform you that my mobile No._ along with the SIM Card has been stolen on (please mention date & time of incident) Accordingly, I hereby request you to kindly block all the incoming and outgoing calls for the said number. Please do the needful and terminate the service on receipt of the said letter. Thanking you, Signature of Claimant Address (TO BE CERTIFIED BY SERVICE PROVIDER) This is to certify that the prepaid/ post paid Mobile No: stands in the name of Mr/Mrs at address AND the customer is using the mobile as Pre paid/ Post Paid as per our records. The SIM card is replaced in lieu of theft of mobile on (please mention date of theft). Seal & Signature of Service Provider (THIS LETTER TO BE ISSUED ONLY BY THE AUTHOURISED OUTLETS OF SERVICE PROVIDER)

5 Divl Office : 663, 1 st Floor, 1 st Main, Defence Colony, 100 Ft Road, Indiranagar 1 st Stage, Bangalore ; TEL : ; FAX WITHOUT PREJUDICE CLAIM PRE-RECEIPT VOUCHER (COLLECTION OF THIS DOCUMENT DOES NOT CONFIRM ADMISSION OF LIABILITY) Received on this (Date ) from THE ORIENTAL INSURANCE CO LTD, BANGALORE, the sum of Rs... (Rupees ) towards full and final settlement of the Claim No under Policy No /48/2016/1759 or /48/2015/695 in respect of FIRE /THEFT / BURGLARY / ACCIDENTAL BREAKDOWN / WATER DAMAGE of handset purchased against Invoice *No *Dated Name and Address : (SIGNATURE OF INSURED) * TO BE FILLED