{"id":629,"title":"ERRORS & OMISSIONS LIABILITY POLICY - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/errors-and-omissions-liability-policy-claim-form","sha256":"b8cc214ffcef7a68ee3812aa3e28ad52dc2d86f447f9495075825da9e0a06670","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to report and claim under the Errors & Omissions Liability Policy.","notes":["Fill the form in BLOCK LETTERS.","Attach all relevant documents as requested.","Attach a cancelled cheque leaf if opting for NEFT payment.","Issue of this claim form is not an admission of liability."],"title":"ERRORS & OMISSIONS LIABILITY POLICY - CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. DETAILS OF INSURED/CLAIMANT","fields":[{"help":"","type":"text","label":"Claim Form No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of insurance period","type":"date","label":"Period of Insurance From  D  D  /  M  M  /  Y  Y  Y  Y   To   D  D  /  M  M  /  Y  Y  Y  Y","options":[],"required":null,"pdf_field":""},{"help":"Select appropriate title and enter full name in block letters","type":"choice","label":"Name of the Insured o Mr.  o Mrs.  o Ms.","options":["Mr.","Mrs.","Ms."],"required":null,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter 6 digit postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter landline number with STD code","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Describe your trade or business","type":"text","label":"Trade or Business","options":[],"required":null,"pdf_field":""},{"help":"Enter date of last premium payment","type":"date","label":"Date of Last Premium Paid D  D  /  M  M  /  Y  Y  Y  Y","options":[],"required":null,"pdf_field":""},{"help":"Specify indemnity limits as per policy","type":"text","label":"Limits of Indemnity under the policy","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"B. DETAILS OF LOSS","fields":[{"help":"Enter date when error or omission occurred","type":"date","label":"1. Date of alleged error omission D  D  /  M  M  /  Y  Y  Y  Y","options":[],"required":null,"pdf_field":""},{"help":"Enter date when claim was made","type":"date","label":"Date claim made D  D  /  M  M  /  Y  Y  Y  Y","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of claimant","type":"text","label":"2. Details Of Claimant Full name of the claimant or potential claimant (i.e. the party making the claim or potential claim upon the Insured)","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's full address","type":"text","label":"Address of the claimant","options":[],"required":null,"pdf_field":""},{"help":"Describe the claim or circumstance in detail","type":"text","label":"3. Details of Claim or Circumstance What is the precise nature of the claim (i.e. the claimant’s allegations) or the fact or circumstance that might give rise to a claim?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if legal proceedings have started and attach documents if yes","type":"yes-no","label":"Have proceedings been commenced? If so, please attach a copy of the court documents.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter date of first awareness","type":"date","label":"On what date did you first become aware of the claim or of the fact or circumstance?","options":[],"required":null,"pdf_field":""},{"help":"Enter date when claim was first intimated","type":"date","label":"On what date was the claim or the intimation of a claim first made to you?","options":[],"required":null,"pdf_field":""},{"help":"Select how claim was first intimated and provide details or attach copy","type":"choice","label":"Was the first intimation of a claim oral or in writing? If in writing please attach a copy. If oral, please give a “first person” account of the conversation, (i.e. “I said”, “He said”).","options":["Oral","In writing"],"required":null,"pdf_field":""},{"help":"Enter claimed amount and its components if known","type":"amount","label":"What amount, if any, is claimed? If known, what does that amount comprise?","options":[],"required":null,"pdf_field":""},{"help":"Provide your response to the claim or circumstance","type":"text","label":"4. Details of Insured’s Response What are your comments in response to the claim or the fact or circumstance that might give rise to a claim?","options":[],"required":null,"pdf_field":""},{"help":"Provide comments on claim amount and potential liability","type":"text","label":"What are your comments on the quantum of the claim and what is your estimate of your Potential monetary liability, if any, to the claimant?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of appointed legal representative if any","type":"text","label":"Have you appointed a solicitor or other lawyer to act for you? If so, what is the lawyers / solicitor name, Firm, address and charge out rates?","options":[],"required":null,"pdf_field":""},{"help":"Attach copies of claimant correspondence","type":"attachment","label":"5. Provide copies of any correspondence you have received from the claimant","options":[],"required":null,"pdf_field":""},{"help":"Attach lawyer correspondence and court documents","type":"attachment","label":"6. Provide copies of any correspondence received from a lawyer along with any court documentation","options":[],"required":null,"pdf_field":""},{"help":"Provide location where court documents were served","type":"text","label":"7. Advise where you were served with the litigation/court documents","options":[],"required":null,"pdf_field":""},{"help":"Enter date when court documents were served","type":"date","label":"8. Advise when you were served with the litigation/court documents","options":[],"required":null,"pdf_field":""},{"help":"Provide name and address of claimant's lawyer","type":"text","label":"9. Name of the claimant’s Lawyer and address","options":[],"required":null,"pdf_field":""},{"help":"Describe preventive actions taken","type":"text","label":"10. What actions you have taken to prevent a reoccurrence or similar claim?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss was reported to an authority","type":"yes-no","label":"If Yes Has the loss been reported to an Authority     o Yes  o No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name of person related to authority report","type":"text","label":"Name of Person's","options":[],"required":null,"pdf_field":""},{"help":"Enter name of authority where loss was reported","type":"text","label":"Name of Authority","options":[],"required":null,"pdf_field":""},{"help":"Enter address of authority","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter reference number given by authority","type":"text","label":"Authority Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Enter name of contact person at authority","type":"text","label":"Contact Person's","options":[],"required":null,"pdf_field":""},{"help":"City of authority","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of authority","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code of authority","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of authority","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of authority","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Email ID of authority","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"C. DETAILS OF OTHER INTEREST","fields":[{"help":"Indicate if insured is sole owner","type":"yes-no","label":"Is the Insured the Sole Owner of the property? o Yes  o No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe nature of interest if not sole owner","type":"text","label":"If ‘No’, specify Nature of Interest","options":[],"required":null,"pdf_field":""},{"help":"Enter names of other interested persons","type":"text","label":"Person/s  who has/have interest on property","options":[],"required":null,"pdf_field":""},{"help":"Address of other interested persons","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"D. DETAILS OF PREVIOUS LOSSES","fields":[{"help":"Provide Date of Loss, Claim Description and Cause of Loss, Value of Loss (Rs.), Insurer","type":"table","label":"Losses during the 3 preceding years","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"E. DETAILS OF OTHER INFORMATION","fields":[{"help":"Indicate if you want to provide additional information","type":"yes-no","label":"Do you wish to provide any other information?    o Yes  o No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"If Yes Please Specify","options":[],"required":null,"pdf_field":""},{"help":"Specify applicable statute or law","type":"text","label":"Give the details of Statute/ Law under which in your opinion liability may arise","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Bank Details and Declaration","fields":[{"help":"Select if you want payment via NEFT","type":"yes-no","label":"Would you like to opt  for NEFT payment? o Yes  o No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach cancelled cheque leaf if opting for NEFT","type":"attachment","label":"If YES, please enclose a cancelled cheque leaf along with the claim form.","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter account holder name as per bank records","type":"text","label":"A/C Holder Name as in Bank Record","options":[],"required":null,"pdf_field":""},{"help":"City of bank branch","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of bank branch","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account No","options":[],"required":null,"pdf_field":""},{"help":"Enter 11 digit IFSC code from cheque leaf","type":"text","label":"IFSC Code (this is a 11 digit code printed on your cheque leaf)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration by Insured","fields":[{"help":"Agree to the declaration","type":"checkbox","label":"I/We hereby declare that the statements made by me/us in this claim form are true to the best of my/our knowledge and belief.","options":[],"required":true,"pdf_field":""},{"help":"Agree to address for GST record","type":"checkbox","label":"I/We here by state that the above mentioned address shall be taken as address on record for the purpose of GST.","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Sign and affix company seal","type":"signature","label":"Insured’s Signature with Company Seal","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":[],"applies_to":"Errors & Omissions Liability Policy claims","attachments":["Copy of court documents if proceedings commenced","Copy of first intimation in writing if applicable","Copies of correspondence from claimant","Copies of correspondence from lawyer and court documentation","Cancelled cheque leaf if opting for NEFT payment"],"declarations":["The insured warrants the truth of all statements and understands that false or fraudulent statements will forfeit the claim and policy.","The insured declares that the statements made in the claim form are true to the best of their knowledge and belief.","The insured agrees that the address given will be used for GST purposes."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"services@indusindinsurance.com","label":"Health Insurance Claims Email","level":1,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"nce Claim\nTravel Insurance Claim\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"indusind@europ-assistance.in","label":"Travel Insurance Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance App\nWebsite:\nOnline Claim Intimation\nOffline Visit:\nLocate your nearest branch\nh","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91 22 48903009","label":"Car Insurance Claim Intimation","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934189","label":"Motor Claims Helpline","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"ation.\nNeed Guidance on Car Coverage?\nTalk to Our Professional Advisors\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nSteps to Take After a Car ​Accident\nThe following steps can expedite the road accident insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934188","label":"Health Claims Helpline","level":null,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"your nearest location.\nExpert health advice you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934184","label":"Travel Claims Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"e you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation\nYour claim gets rejected when you don't gi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+912248903009","label":"Inland Travel Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"rds your registered bank account.\nHow to Contact Us For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 552","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"91-22-67347843","label":"International Travel Helpline (abroad)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 209 5522","label":"International Travel Helpline (in India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance","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/indusind-general-insurance/629-errors-and-omissions-liability-policy-claim-form"}