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L or information Is not readily available please do not delay the dispatch of this form and other particulars may be sent later Claim No : Policy No : Period of Insurance : To A. DETAILS OF INSURED/CLAIMANT Name As Per Policy : Address : City : State : Pin : Contact Details : Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd. Phone Number : Mobile Number : Email ID : Limits of Indemnity under the Policy/IDV (R.

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