{"id":1023,"title":"PUBLIC LIABILITY/PRODUCT LIABILITY 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_Non_Industrial_Claim_Form_8cb68f64e8.pdf","sha256":"27ed294d496016ce432826fb883e25c521ab2ad0517840371b98524660c9b012","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured to claim under a public liability or product liability insurance policy after an accident or incident causing injury or damage.","notes":["The issue of this form is not an admission of liability.","Return the form without delay even if some particulars are not immediately available; they may be forwarded later."],"title":"PUBLIC LIABILITY/PRODUCT LIABILITY CLAIM FORM","submit":{"to":"The Oriental Insurance Company Limited","how":"","address":"Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002"},"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":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy coverage period","type":"text","label":"Period of the Policy","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Limit of Indemnity under the Policy","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of accident","fields":[{"help":"Enter date of accident","type":"date","label":"Date of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Specify time and select A.M. or P.M.","type":"text","label":"Time: A.M./P.M.","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"Location where accident occurred","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Date when accident was first known","type":"date","label":"When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Date when accident was reported to insured","type":"date","label":"When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Date when insurer was first notified","type":"date","label":"When was the claim first notified to the Insurer?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of consequences of the accident","fields":[{"help":"Provide details of injured persons and medical treatment","type":"text","label":"Has any person sustained any injuries in the accident? If so, i) Give name/s address/es and occupation/s of such person/s ii) State where such person was at the time of accident iii) Have the injured persons been removed to hospital or medically attended? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Describe property or livestock damage and owners","type":"text","label":"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 livestock and full description of the property and state the nature of and event of damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of claims made against you and attach copies","type":"text","label":"Has any claim been made upon you by any person? If so, state by whom and give full particulars (claim should be made in writing; attach a copy of the notification received and of the bill if submitted).","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated claim amounts for injuries, property damage, and claims","type":"amount","label":"Estimated amount of claim separately under (a), (b) and (c).","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"List witnesses with their addresses","type":"text","label":"Give, if possible, the names and address of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of authority and attach report copy","type":"text","label":"Has the accident been reported to any authority? If so, state to whom, attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"help":"Describe any action taken by authority","type":"text","label":"What action, if any, has been taken by the authority.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies covering same risk","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risks.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Sign the form","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability and Product Liability insurance claims","attachments":["Copy of the notification received of any claim made upon you","Copy of the bill if submitted","Copy of the report submitted to any 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 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/1023-public-liability-product-liability-claim-form"}