{"id":1021,"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_NEGLIGENCE_POLICY_FOR_MEDICAL_ESTABLISHMENT_028552ae11.pdf","sha256":"0367881db5658da47572803516dd54a69749bf52abb2ec5d8f8ec7c2c8690ae7","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for insured professionals to file a claim under their professional indemnity insurance policy for errors and omissions. It is filled by the insured person or entity who holds the policy.","notes":["The issue of this form is not an admission of liability.","If any particulars cannot be immediately given, they may be forwarded 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":"Your insurance policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Policy coverage period","type":"text","label":"Period of Policy","options":[],"required":null,"pdf_field":""},{"help":"Maximum coverage amount under the 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 happened","type":"date","label":"Date of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location where the incident occurred","type":"text","label":"Place of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Name or description of the person responsible","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 claimant and attach copies of any legal notices or bills","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":"If applicable, provide patient details","type":"text","label":"Name and Address of the Patient.","options":[],"required":null,"pdf_field":""},{"help":"Age and occupation of the claimant or patient","type":"text","label":"His age and occupation.","options":[],"required":null,"pdf_field":""},{"help":"Date of first consultation","type":"date","label":"When did he first consult.","options":[],"required":null,"pdf_field":""},{"help":"Current physical condition of the claimant or patient","type":"text","label":"His general physical condition now.","options":[],"required":null,"pdf_field":""},{"help":"Any other relevant information about the claim","type":"text","label":"Give full particulars of any other relevant aspect","options":[],"required":null,"pdf_field":""},{"help":"Amount of damages claimed","type":"amount","label":"Amount claimed as damage from you","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Witness and Authority Details","fields":[{"help":"Details of witnesses","type":"text","label":"Give the names and addresses of Person who witnessed the incident","options":[],"required":null,"pdf_field":""},{"help":"Name of authority and attach report copy if available","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 authorities","type":"text","label":"What action, if any, has been taken by the authority ?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"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":""}],"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","type":"signature","label":"Insured’s Signature","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured 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 insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Date of witness signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Professional Indemnity Errors & Omissions Insurance 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 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, suppression 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/1021-claim-form-for-professional-indemnity-errors-and-omissions-insurance-for-charter"}