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
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 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

Signature of the Insured

Seal and Signature of Police Station

Address:

*NAME:
*DESIGNATION:

Place:
*PHONE NUMBER:
Date:
* Compulsory fields