{"id":1305,"title":"PUBLIC LIABILITY / PRODUCT LIABILITY INSURANCE - CLAIM FORM","purpose":"claim","insurer":{"slug":"united-india-insurance","name":"United India Insurance Company Limited"},"source_pdf":"https://uiic.co.in/web/sites/default/files/Policy-Document/Public%20Liability%20Ins%20Claim%20Form.pdf","sha256":"430ebd3a6bbfef77180cbd1954cc69f42a317841ec03fdff746924a0911f7bf0","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person or entity to claim under public liability or product liability insurance policies after an accident or incident.","notes":["The issue of this form is not to be taken as an admission of liability","Attach copies of relevant documents as indicated","Complete and return the form promptly"],"title":"PUBLIC LIABILITY / PRODUCT LIABILITY INSURANCE - CLAIM FORM","submit":{"to":"the Company","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Claim Details","fields":[{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Name of Insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"c) Policy number:","options":[],"required":null,"pdf_field":""},{"help":"Write the policy coverage period","type":"text","label":"d) Period of the Policy:","options":[],"required":null,"pdf_field":""},{"help":"Specify the indemnity limits as per policy","type":"text","label":"e) Limits of Indemnity under the Policy:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Date when the accident happened","type":"date","label":"a) Date of occurrence:","options":[],"required":null,"pdf_field":""},{"help":"Location where the accident occurred","type":"text","label":"b) Place of accident:","options":[],"required":null,"pdf_field":""},{"help":"Date when the insured first became aware of the accident","type":"date","label":"c) When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Date when the accident was reported to the insured","type":"date","label":"d) When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Date and time when claim was first notified to insurer","type":"date","label":"e) When was the claim first notified to the Insurer? Date: Time --------- A.M./P.M","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident","fields":[{"help":"Provide details of injured persons and medical attention","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":""},{"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 extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Details of any claims made against you; 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":""},{"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":""}],"filled_by":"insured"},{"title":"Additional Details","fields":[{"help":"List witnesses with their contact details","type":"text","label":"a) Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"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 and attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"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":""},{"help":"Details of other insurance policies covering the same risk","type":"text","label":"d) 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":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured or authorized person","type":"signature","label":"Insured’s Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["The completion and return of this form to the Company should not be delayed","If any particulars cannot be immediately given, they may be forwarded afterwards as soon as possible"],"applies_to":"Public Liability / Product Liability Insurance claims","attachments":["Copy of the notification received if claim has been 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":"mayfair.claims@mayfairwecare.com","label":"Overseas Mediclaim Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Worldwide - Excluding USA & Canada -","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"mayfairassist@mayfairwecare.com","label":"Overseas Mediclaim Medical Emergency Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"://www.mayfairwecare.com/contact/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Wor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18004190133","label":"Overseas Mediclaim Policy Toll-Free Number (India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"l - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact/\nWebsite\nhttps://w","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18888811701","label":"Overseas Mediclaim Policy Toll-Free Number (United States)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"ss\nTower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Loc","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08083045211","label":"Overseas Mediclaim Policy Toll-Free Number (United Kingdom)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"nowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please v","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18885192693","label":"Overseas Mediclaim Policy Toll-Free Number (Canada)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"annerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.may","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8003211710","label":"Overseas Mediclaim Policy Toll-Free Number (Singapore)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"lore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001236889","label":"General Contact Number","level":null,"hours":null,"applies_to":"all","source_url":"https://uiic.co.in/web/","quote":"Links\nCustomer Portal\nKYC Process\nFacebook\nInstagram\nYoutube\nTwitter\nOffice Locator\nIntermediary Portal\nDigi Locker\ntel:18001236889","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/united-india-insurance/1305-public-liability-product-liability-insurance-claim-form"}