UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO. 24 WHITES RD, CHENNAI -600 014

PUBLIC LIABILITY / PRODUCT LIABILITY INSURANCE - CLAIM FORM

Address: Policy No.-------------------------------------
Claim No. -------------------------------------
The issue of this form is not to be taken as an admission of liability.
The completion and return of this from to the Company should not be delayed. If any of the particulars
required cannot be immediately given, they may be forwarded to the Company afterwards as soon as
possible.
1. a) Name of Insured:
b) Address:
c) Policy number:
d) Period of the Policy:
e) Limits of Indemnity under the Policy:
2. Particulars of accident:
a) Date of occurrence:
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?
Date:
Time --------- A.M./P.M
C
UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO. 24 WHITES RD, CHENNAI -600 014
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 extent of damage.
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).
d) Estimated amount of claim separately under (a),
(b) and (c).
4. a) Give, if possible, the names and addresses of all
witnesses to the accident.
b) Has the accident been reported to any authority?
If so, state to whom and 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 risk.
I/We, the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the
forgoing 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.
Date Insured’s Signature