THE NEW INDIA ASSURANCE
Coun?
(remem tet)
NO CLAIM SELF-DECLARATION
1 Mada khedan he Peon.
bearing the Emirates Id No #8.%..(0&¢. 20657 Ha. Séomtirm that have not made any
surance claims in the past one year and I have previously been insured with the
GaIeynes
| W097 3
ME Nee Le
cm
| understand that The New India Assurance Company, Dubai reserves the right to avoid an
insurance claim should this information be incorrect. Also If The New India Assurance
Company, Dubai finds any accident prior to NIA’s policy, the company has the right to send
the vehicle to their panel garage for repair and the agency repair stated in the policy
schedule will automatically become void.
Regards,
Signature: .
Mobiles ..056, ~he2stge ,
“The New India Assurance Comony Ltd P.0 Box $701, Duba, UAE, Tel +971 43525563/3522To,
The New India Assurance Co. LTD.
Dubai, UAE
| hereby declare that after the expiry date of my car
insurance (17/08/2017) there is no accident as on
20/08/2017.
Chassis No. LUCCR2629G3406015
Plate No. 152196
Kindly provide the insurance
A ra
(JOE NADAKKALAN KOCHAPPAN)