{"id":486,"title":"CLAIM FORM FOR PUBLIC LIABILITY INSURANCE (Under Public Liability Insurance Act, 1991)","purpose":"claim","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/public-liability-act--claim-_commercial.pdf","sha256":"634d947472cfb950ed5aa52b3b31ee7a318747c9d3f6d88778827c675b4b0e57","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for filing a claim under Public Liability Insurance by the insured party who has experienced or is involved in an accident covered by the policy.","notes":["The issue of this form is not to be taken as an admission of liability.","Do not delay submission of the form if all particulars are not immediately available; missing information may be sent later.","Attach copies of all relevant reports and notices as required.","Sign and date the form at the end.","Politically Exposed Persons (PEPs) must be declared with details if applicable."],"title":"CLAIM FORM FOR PUBLIC LIABILITY INSURANCE (Under Public Liability Insurance Act, 1991)","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Accident and Policy Details","fields":[{"help":"Enter your insurance policy or cover note number","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the accident occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"If available, enter the claim number","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of filling this form","type":"date","label":"Date","options":[],"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 you reported the accident","type":"date","label":"When did you report the accident?","options":[],"required":null,"pdf_field":""},{"help":"Enter the time when the accident occurred (hour and minutes)","type":"text","label":"Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident details","type":"text","label":"PARTICULARS OF ACCIDENT","options":[],"required":null,"pdf_field":""},{"help":"Describe any steps taken to reduce the loss","type":"text","label":"What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies 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":""},{"help":"Provide details of authority reporting and attach relevant reports","type":"text","label":"HAS THE ACCIDENT BEEN REPORTED TO ANY AUTHORITY? IF SO, STATE BY WHOM AND ATTACH A COPY OF THE REPORT SUBMITTED (LIKE METEOROLOGICAL REPORT, POLLUTION CONTROL REPORT ETC.)","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured or claimant","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Full address of the insured or claimant","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number for contact","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Nearby landmark for address clarity","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"City of the insured or claimant","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"State of the insured or claimant","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Answer if you or related persons are Politically Exposed Persons","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answer above is Yes","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Alleged Claim or Complaint Details","fields":[{"help":"Date of the alleged accident or incident","type":"date","label":"Alleged Date","options":[],"required":null,"pdf_field":""},{"help":"Location of the alleged accident","type":"text","label":"Alleged Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Short description of the accident","type":"text","label":"Brief description of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe the type or nature of accident","type":"text","label":"Nature of accident","options":[],"required":null,"pdf_field":""},{"help":"Time when the accident occurred (hour and minutes)","type":"text","label":"Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"List documents received with the notice","type":"text","label":"Documents received with the notice from the authorities","options":[],"required":null,"pdf_field":""},{"help":"Current status of legal or other proceedings","type":"text","label":"What is the present status of the proceedings?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if previously reported","type":"yes-no","label":"Has the subject matter of the alleged claim/complaint been earlier reported to the Company by an Incident Reporting Form?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of previous incident reporting form if applicable","type":"date","label":"If yes, please provide date of Incident Reporting Form, and append copy thereof.","options":[],"required":false,"pdf_field":""},{"help":"Provide comments or attach incident reporting form","type":"text","label":"If no, kindly submit a duly completed Incident Reporting Form/or set out here the Insured's views/comments on the alleged incident which has resulted in the alleged claim or complaint arising.","options":[],"required":false,"pdf_field":""},{"help":"Attach copies of documents submitted and forwarded by authorities","type":"attachment","label":"Copies of such documents as prescribed by the rules, which are submitted by the claimants to the appropriate authority & forwarded by the appropriate authority.","options":[],"required":null,"pdf_field":""},{"help":"Describe your proposed response","type":"text","label":"The Insured's proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"Attach copy of notice from authority","type":"attachment","label":"Copy of notice forwarded by the appropriate authority.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Claim Details and Legal Advice","fields":[{"help":"Provide details of other claims for the same loss","type":"text","label":"Details of claims if any preferred by the affected party / Insured for the same loss from another source.","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional evidence supporting the claim","type":"text","label":"Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance policies covering the same risk","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if legal advice has been or will be obtained","type":"yes-no","label":"Does the insured propose to/has already availed of, any legal advise","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe steps planned to evaluate legal liability risk","type":"text","label":"If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Consequences of the Accident","fields":[{"help":"Enter the number of victims involved","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Provide details of victims","type":"text","label":"Give name/es, address/es occupation/s of such person/s.","options":[],"required":null,"pdf_field":""},{"help":"Location of victims at time of accident","type":"text","label":"State where such person were at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details for injured persons","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 damage and owner details","type":"text","label":"Has the accident caused damage to property? If so, give name/s and address/es of the owner/s of the property and full description of the property and state the nature and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of losses or injuries","type":"text","label":"Details of loss / injury / death /damage","options":[],"required":null,"pdf_field":""},{"help":"Estimate the financial liability","type":"amount","label":"Estimated quantum of liability under (ii) and (iii) above","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Consent","fields":[{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Claims under Public Liability Insurance Act, 1991","attachments":["Copy of the report submitted to authorities (e.g. Meteorological Report, Pollution Control Report)","Copies of documents submitted by claimants to appropriate authority and forwarded by authority","Copy of notice forwarded by the appropriate authority","Copy of the notification received and bill if claim made in writing","Copy of notice of claimant application forwarded by the appropriate authority under the Act","Copy of the award of the appropriate authority along with the claim form"],"declarations":["The statements given in this form are true, correct and complete.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and claim rights.","Receipt of this form does not constitute admission of liability by the Company.","The insured warrants the truth of all statements and agrees that false or fraudulent statements will forfeit the claim and void the policy.","Consent is given to the Company to verify identity/address proof through Central KYC Registry, UIDAI or other modes."],"dropped_labels":5},"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/icici-lombard-general-insurance/486-claim-form-for-public-liability-insurance-under-public-liability-insurance-act-1"}