{"id":1017,"title":"CLAIM FORM FOR PROFESSIONAL INDEMNITY ERRORS & OMISSIONS INSURANCE FOR CHARTERED ACCOUNTANTS / FINANCIAL ACCOUNTANTS / MANAGEMENT CONSULTANTS / LAWYERS / ADVOCATES / SOLICITORS / COUNSELS","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/PROFESSIONAL_INDEMNITY_CA_MANAGEMENT_CONSULTANTS_LAWYERS_ff388b18f6.pdf","sha256":"4e3c6b1b000fa93bee77a0a29ca7c9cfb59bd81afec36195429256b7f3ed9edd","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for insured professionals such as chartered accountants, management consultants, and lawyers to file a claim under their professional indemnity errors and omissions insurance policy.","notes":["The issue of this form is not an admission of liability.","Do not delay returning the form if some particulars are not immediately available; they may be sent later.","If space is insufficient, attach a separate sheet."],"title":"CLAIM FORM FOR PROFESSIONAL INDEMNITY ERRORS & OMISSIONS INSURANCE FOR CHARTERED ACCOUNTANTS / FINANCIAL ACCOUNTANTS / MANAGEMENT CONSULTANTS / LAWYERS / ADVOCATES / SOLICITORS / COUNSELS","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide your professional qualification and registration number","type":"text","label":"Qualification Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Specify the policy coverage period","type":"text","label":"Period of Policy","options":[],"required":null,"pdf_field":""},{"help":"State the indemnity limits as per your policy","type":"text","label":"Limits of Indemnity under the policy.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Incident","fields":[{"help":"Date when the incident occurred","type":"date","label":"Date of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location where the incident happened","type":"text","label":"Place of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Name the person responsible for the injury or loss","type":"text","label":"Who is directly responsible for the injury/ loss?","options":[],"required":null,"pdf_field":""},{"help":"Describe any treatment given related to the incident","type":"text","label":"Give details of treatment","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Name of the claimant and attach copies of any written claims or legal notices","type":"text","label":"Who has made the claim on you ? (If claim has been made in writing, attach a copy of the demand/legal notice received and of the bill, if any, submitted).","options":[],"required":null,"pdf_field":""},{"help":"Provide claimant's full name and address","type":"text","label":"Name and Address of the Patient.","options":[],"required":null,"pdf_field":""},{"help":"State claimant's age and occupation","type":"text","label":"His age and occupation.","options":[],"required":null,"pdf_field":""},{"help":"Date when claimant first consulted you","type":"date","label":"When did he first consult.","options":[],"required":null,"pdf_field":""},{"help":"Describe claimant's current physical condition","type":"text","label":"His general physical condition now.","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant details about the claim","type":"text","label":"Give full particulars of any other relevant aspect","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Amount and Witnesses","fields":[{"help":"Specify the amount claimed as damages","type":"amount","label":"Amount claimed as damage from you","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with their names and addresses","type":"text","label":"Give the names and addresses of Person who witnessed the incident","options":[],"required":null,"pdf_field":""},{"help":"Mention if reported to any authority and attach report copy","type":"text","label":"Has the incident been reported to IMC or any other authority ? If so, state to whom and attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"help":"Describe any action taken by the authority","type":"text","label":"What action, if any, has been taken by the authority ?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance and Previous Claims","fields":[{"help":"Provide details of any other insurance covering this risk","type":"text","label":"Give particulars of other insurance if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any previous claims have been made","type":"yes-no","label":"Has any claim been made upon you before.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Signature of witness","type":"signature","label":"Witness : Signature","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Insured’s Signature","options":[],"required":null,"pdf_field":""},{"help":"Name of the person signing","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Address of the person signing","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Date of signing (repeated)","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Professional Indemnity Errors & Omissions Insurance claims for Chartered Accountants, Financial Accountants, Management Consultants, Lawyers, Advocates, Solicitors, Counsels","attachments":["Copy of the demand/legal notice received","Copy of the bill, if any, submitted","Copy of the report submitted to IMC or any other authority"],"declarations":["The insured warrants the truth of the statements to the best of their knowledge and belief.","If any false or fraudulent statement or concealment is made, the claim shall be forfeited and the policy null and void."],"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/1017-claim-form-for-professional-indemnity-errors-and-omissions-insurance-for-charter"}