The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

PUBLIC LIABILITY/PRODUCT LIABILITY CLAIM FORM

Policy No. ………
Claim No………..
(The issue of this form is not be taken as an admission of liability)
The completion and return of this form to the Company should not be delayed if any of the particulars
required cannot be immediately given. They may be forwarded to he Company afterwards as soon as
possible.
1 a) Name of Insured
b) Address:
c) Policy No.
d) Period of the Policy
e) Limit of Indemnity under the Policy
2 Particulars of accident
a) Date of occurrence: Time: A.M./P.M.
b) Place of accident
c) When did you first come to
know of the accident?
d) When was the accident
reported to you?
e) When was the claim first notified
to the Insurer?
3 Particulars of consequences of the accident
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.
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.
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).
d) Estimated amount of claim separately under
(a), (b) and (c).
4 a)Give, if possible, the names and address of all witnesses to the accident.
b) Has the accident been reported to any authority? If so, state to whom,
attach a copy of the report submitted.
c) What action, if any, has been taken by the authority.
d) Give particulars of any other insurance, if any, in respect of the same risks.
Issuing
Office
2
I /we the above named, do hereby, to the best of my knowledge and belief, warrant the truth of the
foregoing statements in every respect; and I/we agree that if I/we have made, or in any further declaration
the company may require in respect of the said accident, shall make any false or fraudulent statement, or
any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and
void.
Insured’s Signature____________
Date______________