{"id":1027,"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_1_808e10a6b3.pdf","sha256":"8815e16d2292184a524a501c47e33c51b119d8cf6d3f29bd2b4f499221f58ed9","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a public or product liability claim by the insured policyholder who has experienced 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 may be forwarded later.","Attach copies of claim notifications and authority reports as applicable."],"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":"a) Name of Insured","options":[],"required":null,"pdf_field":"a Name of Insured b Address c Policy No d Period of the Policy e Limit of Indemnity under the Policy"},{"help":"","type":"text","label":"b) Address","options":[],"required":null,"pdf_field":"a Name of Insured b Address c Policy No d Period of the Policy e Limit of Indemnity under the Policy"},{"help":"Enter your policy number","type":"text","label":"c) Policy No.","options":[],"required":null,"pdf_field":"Policy No"},{"help":"Enter the policy coverage period","type":"text","label":"d) Period of the Policy","options":[],"required":null,"pdf_field":"a Name of Insured b Address c Policy No d Period of the Policy e Limit of Indemnity under the Policy"},{"help":"Enter the indemnity limit as per policy","type":"text","label":"e) Limit of Indemnity under the Policy","options":[],"required":null,"pdf_field":"a Name of Insured b Address c Policy No d Period of the Policy e Limit of Indemnity under the Policy"}],"filled_by":"insured"},{"title":"Particulars of accident","fields":[{"help":"Enter the date and time of the accident","type":"date","label":"a) Date of occurrence: Time: A.M./P.M.","options":[],"required":null,"pdf_field":"Text88"},{"help":"Enter the location where the accident occurred","type":"text","label":"b) Place of accident","options":[],"required":null,"pdf_field":"Text89"},{"help":"Enter the date you first learned about the accident","type":"date","label":"c) When did you first come to know of the accident?","options":[],"required":null,"pdf_field":"Text90"},{"help":"Enter the date the accident was reported to you","type":"date","label":"d) When was the accident reported to you?","options":[],"required":null,"pdf_field":"Text91"},{"help":"Enter the date you first notified the insurer","type":"date","label":"e) When was the claim first notified to the Insurer?","options":[],"required":null,"pdf_field":"Text92"}],"filled_by":"insured"},{"title":"Particulars of consequences of the accident","fields":[{"help":"Provide details of injured persons and medical treatment","type":"text","label":"a) 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":"Text93"},{"help":"Describe property or livestock damage and owners","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 livestock and full description of the property and state the nature of and event of damage.","options":[],"required":null,"pdf_field":"Text94"},{"help":"Provide details of any claims made against you and attach copies","type":"text","label":"c) 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":"Text95"},{"help":"Provide 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":"Text96"}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"List witnesses with their addresses","type":"text","label":"a) Give, if possible, the names and address of all witnesses to the accident.","options":[],"required":null,"pdf_field":"Text97"},{"help":"Provide details of authority notified and attach report copy","type":"text","label":"b) 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":"Text98"},{"help":"Describe any action taken by the authority","type":"text","label":"c) What action, if any, has been taken by the authority.","options":[],"required":null,"pdf_field":"Text99"},{"help":"Provide details of other insurance policies covering the risk","type":"text","label":"d) Give particulars of any other insurance, if any, in respect of the same risks.","options":[],"required":null,"pdf_field":"Text100"}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Sign the form","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":"Public Liability and Product Liability claims","attachments":["Copy of the notification received of any claim made","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":[{"name":"Policy No","page":1,"type":"text","label":"Policy No"},{"name":"Claim No","page":1,"type":"text","label":"Claim No"},{"name":"a Name of Insured b Address c Policy No d Period of the Policy e Limit of Indemnity under the Policy","page":1,"type":"text","label":"a) Name of Insured b) Address: c) Policy No. d) Period of the Policy e) Limit of Indemnity under the Policy"},{"name":"Text88","page":1,"type":"text"},{"name":"Text89","page":1,"type":"text"},{"name":"Text90","page":1,"type":"text"},{"name":"Text91","page":1,"type":"text"},{"name":"Text92","page":1,"type":"text"},{"name":"Text93","page":1,"type":"text"},{"name":"Text94","page":1,"type":"text"},{"name":"Text95","page":1,"type":"text"},{"name":"Text96","page":1,"type":"text"},{"name":"Text97","page":1,"type":"text"},{"name":"Text98","page":1,"type":"text"},{"name":"Text99","page":1,"type":"text"},{"name":"Text100","page":1,"type":"text"},{"name":"Text101","page":1,"type":"text"},{"name":"Text102","page":1,"type":"text"},{"name":"Text103","page":1,"type":"text"},{"name":"Text104","page":1,"type":"text"},{"name":"Text105","page":1,"type":"text"},{"name":"Text106","page":1,"type":"text"},{"name":"Text107","page":1,"type":"text"},{"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/1027-public-liability-product-liability-claim-form"}