{"id":1025,"title":"CLAIM FORM FOR INSURANCE UNDER PUBLIC LIABILITY INSURANCE ACT 1991","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_Act_Insurance_Claim_Form_c297da87d4.pdf","sha256":"a4cde1e5743ac8afd8a7197da8f50962cbff7499312c0b9a0910786698d1567e","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim insurance under the Public Liability Insurance Act 1991 after an accident causing injury or damage.","notes":["The issue of this form is not an admission of liability.","Complete and return the form without delay; missing particulars can be sent later."],"title":"CLAIM FORM FOR INSURANCE UNDER PUBLIC LIABILITY INSURANCE ACT 1991","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details and Policy Information","fields":[{"help":"","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Policy coverage period","type":"text","label":"Period of the Policy","options":[],"required":null,"pdf_field":""},{"help":"Enter limits of indemnity as per policy","type":"text","label":"Limits of Indemnity under the Policy : AoA__________    AoY_____________","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Date when accident happened","type":"date","label":"Date of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Specify A.M. or P.M.","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Exact location of accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Date/time when accident was first known","type":"text","label":"When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Date/time accident was reported to insured","type":"text","label":"When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Date claim was first notified","type":"text","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":"List injured persons with details","type":"text","label":"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":""},{"help":"Location of injured persons during accident","type":"text","label":"State where such person was at the time of accident.","options":[],"required":null,"pdf_field":""},{"help":"Details of medical treatment or hospitalisation","type":"text","label":"Have the injured persons been removed to hospital or medically attended? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Details of property/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 the livestock and full description of the property and state the nature of and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Details of claims made against insured; attach copies if written","type":"text","label":"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":""},{"help":"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":"Witnesses and Authority Reporting","fields":[{"help":"List witnesses with contact details","type":"text","label":"Give, if possible, the names and addresses of all witnesses to the accident","options":[],"required":null,"pdf_field":""},{"help":"Details of authority reported to; attach report copy","type":"text","label":"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":""},{"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":""}],"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":""},{"help":"Information on previous similar claims or accidents","type":"text","label":"Details of similar accidents / claims in the past (if any)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Signature of the insured person","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"claims under Public Liability Insurance Act 1991","attachments":["If claim has been made in writing, attach a copy of the notification received and of the bill, If submitted","Attach a copy of the report submitted to the authority if accident was reported"],"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/1025-claim-form-for-insurance-under-public-liability-insurance-act-1991"}