{"id":1174,"title":"PRODUCT LIABILITY CLAIM FORM","purpose":"claim","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/claim/PRODUCT-LIABILITY-CLAIM-FORM.pdf","sha256":"8dc25b66c370d8a3454c38c41cc62d500accad0a75bcff5186b9d4c86ff49684","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured to report and claim for a product liability incident involving injury or damage caused by a product covered under their insurance policy.","notes":["The issue of this form is not an admission of liability.","Do not delay returning the form if some particulars are not immediately available; they may be forwarded later."],"title":"PRODUCT LIABILITY CLAIM FORM","submit":{"to":"Shriram General Insurance Co. Ltd.","how":"","address":"E-8, EPIP, RIICO Industrial Area, Sitapura, Jaipur (Raj.)-302022"},"purpose":"claim","sections":[{"title":"Insured and Policy Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured person or entity","type":"text","label":"Name of Insured:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the insured","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter the start date of the policy period","type":"date","label":"Policy Period: From","options":[],"required":null,"pdf_field":""},{"help":"Enter the end date of the policy period","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Enter the limit of indemnity for AOA","type":"amount","label":"Limits of Indemnity under the Policy: AOA Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter the limit of indemnity for AOY","type":"amount","label":"AOY Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Enter the date when the accident occurred","type":"date","label":"Date of occurrence:","options":[],"required":null,"pdf_field":""},{"help":"Enter the time of accident and select A.M. or P.M.","type":"text","label":"Time:","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"Enter the location where the accident happened","type":"text","label":"Place of accident:","options":[],"required":null,"pdf_field":""},{"help":"Enter the date or time when you first became aware of the accident","type":"text","label":"When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Enter the date or time when the accident was reported to you","type":"text","label":"When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Enter the date or time when the insurer was first notified of the claim","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 their names, addresses, and occupations","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":"Describe the location of injured persons at the time of accident","type":"text","label":"State where such person/s was/were at the time of accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of medical treatment or hospital admission","type":"text","label":"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 with owner details and damage extent","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 extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any claims made against you and attach copies if available","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":"Provide estimated claim amounts for injuries, property damage, and claims made","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 names and addresses","type":"text","label":"Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of authority reported to and 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 the authority","type":"text","label":"What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering the same risk","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Sign the form to confirm the truthfulness of the statements","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["Copy of the notification received if claim made in writing","Copy of the bill if submitted","Copy of the report submitted to authority if accident reported"],"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 null and void."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"chd@shriramgi.com","label":"Help Desk Email ID for claim intimation","level":null,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ase download the CLAIM INTIMATION SHEET, fill it and send it to our Help\n                            Desk via Email ID (chd@shriramgi.com)\nNote:\nPlease ensure that the following information is ready with you at the time of\n                            claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-300-30000","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 4:00 AM to Midnight 12:00","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"Option 1:\nIntimate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-3009","label":"Customer Help Desk Toll Free","level":null,"hours":"7 Days in week 9:30 am to 5:30 pm","applies_to":"all","source_url":"https://www.shriramgi.com/claims","quote":"ate a claim online on Shriram General Insurance website or over the\n                            phone at 1800-300-30000/1800-103-3009 or through the MYSGI App\nOption 2:\nPlease download the CLAIM INTIMATION SHEET, fill it and send it to our Help","fetched_at":"2026-10-20"}],"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/shriram-general-insurance/1174-product-liability-claim-form"}