{"id":1026,"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_1_6b03bbdada.pdf","sha256":"10f40575059dcbeb6362cd416cb5be9bfb6ddcf8bbc3e5d7ded0091e2a440a4d","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Public Liability Insurance Act 1991 by the insured person or entity who holds the policy.","notes":["Attach copies of any written claim notifications and bills if submitted.","Attach copy of the report submitted to any authority if the accident was reported.","The form must be signed and dated by the insured."],"title":"CLAIM FORM FOR INSURANCE UNDER PUBLIC LIABILITY INSURANCE ACT 1991","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":"undefined"},{"help":"","type":"text","label":"(b) Address","options":[],"required":null,"pdf_field":"b Address"},{"help":"","type":"text","label":"(c) Policy Number","options":[],"required":null,"pdf_field":"c Policy Number"},{"help":"","type":"text","label":"(d) Period of the Policy","options":[],"required":null,"pdf_field":"undefined_3"},{"help":"Enter AoA and AoY values","type":"text","label":"(e) Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":"e Limits of Indemnity under the Policy  AoA"},{"help":"","type":"text","label":"AoY","options":[],"required":null,"pdf_field":"AoY"}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"","type":"date","label":"(a) Date of occurrence","options":[],"required":null,"pdf_field":"c When did you first come to know of the accident"},{"help":"Enter time with A.M./P.M.","type":"text","label":"Time","options":[],"required":null,"pdf_field":"Time"},{"help":"","type":"text","label":"(b) Place of accident","options":[],"required":null,"pdf_field":"undefined_6"},{"help":"","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":"undefined_4"},{"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":"","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 property and damage","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":"the property and state the nature of and extent of damage 1"},{"help":"Attach copies if available","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":"so give particulars 1"},{"help":"","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 Report","fields":[{"help":"","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":"Attach copy of report","type":"text","label":"(b) 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":"of the report submitted 1"},{"help":"","type":"text","label":"(c) What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":"c 1"}],"filled_by":"insured"},{"title":"Other Insurance and Past Claims","fields":[{"help":"","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":"Give particulars of any other insurance if any in respect of the same"},{"help":"","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":"","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":"Insureds Signature"},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Date"}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability Insurance Act 1991 claims","attachments":["copy of the notification received if claim made in writing","copy of the bill if submitted","copy of the report submitted to authority"],"declarations":["The issue of this form is not to be taken as an admission of liability.","The completion and return of this form should not be delayed if any particulars cannot be immediately given; they may be forwarded later.","The insured warrants the truth of the statements and agrees that any false or fraudulent statement or concealment will forfeit the claim and void the policy."],"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":"b Address","page":1,"type":"text","label":"b) Address"},{"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":"so give particulars 1","page":2,"type":"text","label":"so, give particulars [1]"},{"name":"so give particulars 2","page":2,"type":"text","label":"so, give particulars [2]"},{"name":"so give particulars 3","page":2,"type":"text","label":"so, give particulars [3]"},{"name":"the property and state the nature of and extent of damage 1","page":2,"type":"text","label":"the property and state the nature of and extent of damage [1]"},{"name":"the property and state the nature of and extent of damage 2","page":2,"type":"text","label":"the property and state the nature of and extent of damage [2]"},{"name":"and of the bill If submitted 1","page":2,"type":"text","label":"and of the bill, If submitted [1]"},{"name":"and of the bill If submitted 2","page":2,"type":"text","label":"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 3","page":2,"type":"text","label":"4. (a) Give, if possible, the names and addresses of all witnesses to the accident [3]"},{"name":"of the report submitted 1","page":2,"type":"text","label":"of the report submitted [1]"},{"name":"of the report submitted 2","page":2,"type":"text","label":"of the report submitted [2]"},{"name":"c 1","page":2,"type":"text","label":"c [1]"},{"name":"c 2","page":2,"type":"text","label":"c [2]"},{"name":"Give particulars of any other insurance if any in respect of the same","page":2,"type":"text","label":"Give particulars of any other insurance, if any, in respect of the same"},{"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":"6","page":2,"type":"text","label":"6"},{"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/1026-claim-form-for-insurance-under-public-liability-insurance-act-1991"}