{"id":1015,"title":"PEDAL CYCLE CLAIM FORM","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/CLAIM_FORM_PEDAL_CYCLE_2e56503319.pdf","sha256":"f5fa3c6fca7deb3c348b75a330135cfab1cbb585eb7710fde246c5283a295045","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim insurance for loss or damage to a pedal cycle under their policy.","notes":[],"title":"PEDAL CYCLE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Name and Business of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of insurance period","type":"date","label":"Period of Insurance From_____________to____________","options":[],"required":null,"pdf_field":""},{"help":"Provide date and recipient of last premium payment","type":"text","label":"When and to whom last premium paid","options":[],"required":null,"pdf_field":""},{"help":"Provide bicycle number and description","type":"text","label":"No. and description of Bicycle","options":[],"required":null,"pdf_field":""},{"help":"Provide manufacturer details","type":"text","label":"Name and address of Maker","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"1. PARTICULARS OF ACCIDENT","fields":[{"help":"Date of accident","type":"date","label":"1. State when the accident occurred","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"2. Where did it occur","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident in detail","type":"text","label":"3. How did it occur (This must be fully answered)","options":[],"required":true,"pdf_field":""},{"help":"Provide details if another party was negligent","type":"text","label":"4. If caused by negligence of another party, Give name and address","options":[],"required":null,"pdf_field":""},{"help":"Provide witness details","type":"text","label":"5. Name and address of Witness of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe damage to the cycle","type":"text","label":"6. Nature of damage done to cycle","options":[],"required":null,"pdf_field":""},{"help":"Provide repairer details if cycle is under repair","type":"text","label":"7. Name and address of cycle repairers who has cycle in hand to repair","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"2. PARTICULARS OF THEFT","fields":[{"help":"Date of theft","type":"date","label":"1. State when the theft occurred","options":[],"required":null,"pdf_field":""},{"help":"Location of theft","type":"text","label":"2. Where did it occur?","options":[],"required":null,"pdf_field":""},{"help":"Describe how the theft happened","type":"text","label":"3. How did it occur?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if cycle was unattended and duration","type":"text","label":"4. Was cycle left unattended? If so, for how long","options":[],"required":null,"pdf_field":""},{"help":"Describe security measures taken","type":"text","label":"5. What precautions were taken to protect cycle?","options":[],"required":null,"pdf_field":""},{"help":"Provide police station name","type":"text","label":"6. Name of the police station at which report has been lodged","options":[],"required":null,"pdf_field":""},{"help":"Indicate if police have any leads","type":"text","label":"7. State whether police have any clue","options":[],"required":null,"pdf_field":""},{"help":"Select purpose of cycle use","type":"choice","label":"8. State for what purpose cycle was being used Business or pleasure","options":["Business","pleasure"],"required":null,"pdf_field":""},{"help":"Provide other insurance details if any","type":"text","label":"9. Is cycle at present insured with any other Insurance Company If so give details","options":[],"required":null,"pdf_field":""},{"help":"Enter claim amount","type":"amount","label":"10. Amount Claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"DECLARATION","fields":[{"help":"Name of witness to declaration","type":"text","label":"Witness","options":[],"required":null,"pdf_field":""},{"help":"Signature of claimant","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Address of claimant","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["The claimant declares that the particulars given are true in every respect.","The cycle claimed for is the same as covered under the policy."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/oriental-insurance/1015-pedal-cycle-claim-form"}