{"id":1022,"title":"PUBLIC LIABILTY 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/Public_liability_Industrial_Claim_Form_1_977040e8c6.pdf","sha256":"1b369ed8c44d888c0498f44894265f386e78c59c0780a5e2e1c636a724ce62ec","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to report and claim for a public liability accident under their insurance policy.","notes":["The form should be completed and returned to the company as soon as possible.","Attach copies of any written claim notifications and bills if submitted.","Attach copies of any reports submitted to authorities.","Use block letters where possible."],"title":"PUBLIC LIABILTY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":"Policy No"},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":"Claim No"},{"help":"","type":"text","label":"(a) Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"(b) Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"(c) Policy Number","options":[],"required":null,"pdf_field":"c Policy Number"},{"help":"Policy start and end dates","type":"text","label":"(d) Period of the Policy","options":[],"required":null,"pdf_field":""},{"help":"Enter AoA and AoY values as per policy","type":"text","label":"(e) Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":"e Limits of Indemnity under the Policy  AoA"}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Date when the accident happened","type":"date","label":"(a) Date of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Time of accident with A.M./P.M.","type":"text","label":"Time","options":[],"required":null,"pdf_field":"Time"},{"help":"Exact location of the accident","type":"text","label":"(b) Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Date when insured first learned about the accident","type":"date","label":"(c) When did you first come to know of the accident?","options":[],"required":null,"pdf_field":"c When did you first come to know of the accident"},{"help":"","type":"date","label":"(d) When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"(e) When was the claim first notified to the Insurer?","options":[],"required":null,"pdf_field":"e When was the claim first notified to the Insurer"}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident","fields":[{"help":"List injured persons with full details","type":"text","label":"(a) Has any person sustained any injuries in the accident? If so, give name/s, address/es and occupation/s of such person/s.","options":[],"required":null,"pdf_field":"Give names  addresses and occupations  of such persons"},{"help":"Describe damaged property or livestock and owner details","type":"text","label":"(b) Has the accident caused damage to property or livestock? If so, give name/s and address/es of the owner/s of the property and/or the livestock and full description of the property and state the nature of and extent of damage.","options":[],"required":null,"pdf_field":"full description of the property and state the nature of and extent of damage 1"},{"help":"Details of claims made against you","type":"text","label":"(c) Has any claim been made upon you by any person? If so, state by whom and give full particulars (If claim has been made in writing, attach a copy of the notification received and of the bill, If submitted).","options":[],"required":null,"pdf_field":"notification received and of the bill If submitted 1"},{"help":"Estimated claim amounts for injuries, property damage, and claims","type":"amount","label":"(d) Estimated amount of claim separately under (a), (b) and (c)","options":[],"required":null,"pdf_field":"d Estimated amount of claim separately under a b and c 1"}],"filled_by":"insured"},{"title":"Witnesses and Authority Action","fields":[{"help":"List witnesses with contact details","type":"text","label":"(a) Give, if possible, the names and addresses of all witnesses to the accident","options":[],"required":null,"pdf_field":"4 a Give if possible the names and addresses of all witnesses to the accident 1"},{"help":"Details of authority report and attach copy","type":"text","label":"(a) Has the accident been reported to any authority? If so, state to whom and attach a copy of the report submitted.","options":[],"required":null,"pdf_field":"attach a copy of the report submitted 1"},{"help":"Describe any action taken by authorities","type":"text","label":"(b) What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":"b What action if any has been taken by the authority 1"}],"filled_by":"insured"},{"title":"Other Insurance and Past Claims","fields":[{"help":"Details of other insurance policies covering this risk","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":"5 Give particulars of any other insurance if any in respect of the same"},{"help":"Information on previous similar claims","type":"text","label":"Details of similar accidents / claims in the past (if any)","options":[],"required":null,"pdf_field":"Details of similar accidents  claims in the past if any"}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Sign here","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":"Insureds Signature"},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Date"}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["copy of the notification received and of the bill, If submitted","copy of the report submitted"],"declarations":["The issue of this form is not an admission of liability.","Completion and return of this form should not be delayed if some particulars are not immediately available.","If any false or fraudulent statement or concealment is made, the claim shall be forfeited and the policy null and void.","The insured warrants the truth of the statements to the best of their knowledge and belief."],"dropped_labels":2},"pdf_fields":[{"name":"Policy No","page":1,"type":"text","label":"Policy No"},{"name":"Claim No","page":1,"type":"text","label":"Claim No"},{"name":"undefined","page":1,"type":"text","label":"undefined"},{"name":"undefined_2","page":1,"type":"text","label":"undefined"},{"name":"c Policy Number","page":1,"type":"text","label":"c) Policy Number"},{"name":"undefined_3","page":1,"type":"text","label":"undefined"},{"name":"undefined_4","page":1,"type":"text","label":"undefined"},{"name":"e Limits of Indemnity under the Policy  AoA","page":1,"type":"text","label":"e) Limits of Indemnity under the Policy : AoA"},{"name":"AoY","page":1,"type":"text","label":"AoY"},{"name":"undefined_5","page":1,"type":"text","label":"undefined"},{"name":"Time","page":1,"type":"text","label":"Time"},{"name":"undefined_6","page":1,"type":"text","label":"undefined"},{"name":"c When did you first come to know of the accident","page":1,"type":"text","label":"c) When did you first come to know of the accident"},{"name":"e When was the claim first notified to the Insurer","page":1,"type":"text","label":"e) When was the claim first notified to the Insurer"},{"name":"Give names  addresses and occupations  of such persons","page":1,"type":"text","label":"Give name/s , address/es and occupation/s  of such person/s"},{"name":"undefined_7","page":1,"type":"text","label":"undefined"},{"name":"State where such person was at the time of accident","page":1,"type":"text","label":"State where such person was at the time of accident"},{"name":"attended If so give particulars","page":1,"type":"text","label":"attended? If so, give particulars"},{"name":"1","page":2,"type":"text","label":"[1]"},{"name":"2","page":2,"type":"text","label":"[2]"},{"name":"3","page":2,"type":"text","label":"[3]"},{"name":"full description of the property and state the nature of and extent of damage 1","page":2,"type":"text","label":"full description of the property and state the nature of and extent of damage [1]"},{"name":"full description of the property and state the nature of and extent of damage 2","page":2,"type":"text","label":"full description of the property and state the nature of and extent of damage [2]"},{"name":"notification received and of the bill If submitted 1","page":2,"type":"text","label":"notification received and of the bill, If submitted [1]"},{"name":"notification received and of the bill If submitted 2","page":2,"type":"text","label":"notification received and of the bill, If submitted [2]"},{"name":"d Estimated amount of claim separately under a b and c 1","page":2,"type":"text","label":"d) Estimated amount of claim separately under (a), (b) and (c [1]"},{"name":"d Estimated amount of claim separately under a b and c 2","page":2,"type":"text","label":"d) Estimated amount of claim separately under (a), (b) and (c [2]"},{"name":"4 a Give if possible the names and addresses of all witnesses to the accident 1","page":2,"type":"text","label":"4. (a) Give, if possible, the names and addresses of all witnesses to the accident [1]"},{"name":"4 a Give if possible the names and addresses of all witnesses to the accident 2","page":2,"type":"text","label":"4. (a) Give, if possible, the names and addresses of all witnesses to the accident [2]"},{"name":"attach a copy of the report submitted 1","page":2,"type":"text","label":"attach a copy of the report submitted [1]"},{"name":"attach a copy of the report submitted 2","page":2,"type":"text","label":"attach a copy of the report submitted [2]"},{"name":"b What action if any has been taken by the authority 1","page":2,"type":"text","label":"b) What action, if any, has been taken by the authority [1]"},{"name":"b What action if any has been taken by the authority 2","page":2,"type":"text","label":"b) What action, if any, has been taken by the authority [2]"},{"name":"5 Give particulars of any other insurance if any in respect of the same","page":2,"type":"text","label":"5. Give particulars of any other insurance, if any, in respect of the same"},{"name":"undefined_8","page":2,"type":"text","label":"undefined"},{"name":"Details of similar accidents  claims in the past if any","page":2,"type":"text","label":"Details of similar accidents / claims in the past (if any"},{"name":"Insureds Signature","page":2,"type":"signature","label":"Insured’s Signature"},{"name":"Date","page":2,"type":"text","label":"Date"}],"fillable_pdf":true,"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/1022-public-liabilty-claim-form"}