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

PEDAL CYCLE CLAIM FORM
(The issue of this from is not to be taken as an admission of Liability)
Please answer all questions fully. It will avoid unnecessary correspondence and
consequent delay in the settlement of claim

Name and Business of the Insured
__________________________________________________________________________
Address
__________________________________________________________________________
Policy Number
__________________________________________________________________________
Period of Insurance From_____________to____________
__________________________________________________________________________
When and to whom last premium paid
__________________________________________________________________________
No. and description of Bicycle:
__________________________________________________________________________
Name and address of Maker:
__________________________________________________________________________
1. PARTICULARS OF ACCIDENT
1. State when the accident occurred:
2. Where did it occur:
3. How did it occur:
(This must be fully answered)
4. If caused by negligence of another party,
Give name and address:
5. Name and address of Witness of accident:
6. Nature of damage done to cycle:
7. Name and address of cycle repairers who
has cycle in hand to repair:
Issuing
Office
2
2. PARTICULARS OF THEFT
1. State when the theft occurred:
2. Where did it occur?
3. How did it occur?
4. Was cycle left unattended?
If so, for how long
5. What precautions were taken to protect cycle?
6. Name of the police station at which report has been lodged
7. State whether police have any clue.
8. State for what purpose cycle was being
used Business or pleasure
9. Is cycle at present insured with any other
Insurance Company
If so give details
10. Amount Claimed:
DECLARATION
I/we hereby declare that the foregoing particulars are true in every respect, and that cycle for which I/we
am/are claiming is the same for which the above mentioned policy was taken out.
Witness:____________ Signature______________
Address:______________________ Date________
_____________________________
_____________________________