Seal and Signature of Police Station

*NAME:

*DESIGNATION:

*PHONE NUMBER:

Signature of the Insured

Address:

Place:

Date:

FORM 2A Intimation Id : AD_AT_270615_2614905

(FORMAT OF POLICE COMPLAINT)

Date: *___________

To

Police Station In-charge

*___________________

___________________

___________________

Reg: Request for registering Complaint - Mobile *IMEI No (Kindly mention both IMEI if handset is dual SIM).

IMEI No: *359227065058618

Make - Model : Ipone 6_iPhone7_2

Dear Sir,

I regret to inform you that my above mentioned Mobile Phone purchased vide Invoice No *910 dated 21-Jun-2015, bearing IMEI No.

*359227065058618 has been stolen on *26-Jun-2015 (please mention date of incident)

Brief Description of Incidence:

Lost apple iPhone 6 near gate no. 1 in Jama Masjid on 26 June 2015 at 20.00 hrs.

I was having PRE-PAID / POST-PAID facility and was using the services of Service Provider (please mention service provider

*___________________ and my mobile number for same was (please mention Mobile No.)like Vodafone, Airtel, BSNL etc)

*______________________. I have already informed the service provider to terminate the services (incoming and 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 NEW INDIA ASSURANCE COMPANY LIMITED, BANGALORE REGIONAL

OFFICE, 2B, UNITY BLDG ANNEXE, MISSION ROAD, BANGALORE 560027 with whom I have filed an insurance claim.

Thanking you

* Compulsory fields