{"id":1061,"title":"Claim Form - Fidelity Guarantee Insurance","purpose":"claim","insurer":{"slug":"raheja-qbe-general-insurance","name":"Raheja QBE General Insurance Co. Ltd."},"source_pdf":"https://rahejaqbe.com/uploads/images/fidelity-guarantee/pdf/download/claim-form.pdf","sha256":"1bf0736a47c3f29cc642bc043aeab1b460c69478bae7162939aceb3a3e950237","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim under a Fidelity Guarantee Insurance policy for losses due to employee defalcation.","notes":["If the matter has not been reported to Police, lodge FIR at the earliest.","Attach copy of FIR if reported.","Use original documents and provide full details as requested."],"title":"Claim Form - Fidelity Guarantee Insurance","submit":{"to":"Raheja QBE General Insurance Company Limited","how":"","address":"Commerz, 10 Floor, International Business Park, Oberoi Garden City, Western Express Highway, Goregaon(E) Mumbai – 400 063"},"purpose":"claim","sections":[{"title":"A. Insured’s Details","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Tel No. Office","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Fax No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Contact Person’s Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"e-mail","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Policy Details","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of the insurance period","type":"date","label":"Period of Insurance to","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Loss Details","fields":[{"help":"Enter the total amount of loss in rupees","type":"amount","label":"Amount of loss sustained Rs.","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss was discovered","type":"date","label":"Date of discovery of defalcation","options":[],"required":null,"pdf_field":""},{"help":"Specify the dates when the defalcation occurred","type":"text","label":"Dates of defalcation","options":[],"required":null,"pdf_field":""},{"help":"Provide full details of the employee involved","type":"text","label":"Name, designation and address of defaulting employee","options":[],"required":null,"pdf_field":""},{"help":"Explain the method of defalcation in detail","type":"text","label":"Describe how the defalcation was committed.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No; if Yes, attach copy of FIR; if No, lodge FIR at earliest","type":"yes-no","label":"Has the matter been reported to Police? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the number of other employees in the same category","type":"number","label":"How many other employees fall in the same category as the defaulting employee?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. Details of defaulting employee","fields":[{"help":"Describe the employee's role and location","type":"text","label":"In what capacity the defaulting employee was engaged and where?","options":[],"required":null,"pdf_field":""},{"help":"Explain the process by which the employee received the money","type":"text","label":"How did the money reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"Provide the maximum amount held and duration","type":"text","label":"State the largest sum held by him at any one time and also mention for how long.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Was she/he allowed to pay out any amounts in insured’s behalf? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name and designation of authorizing person","type":"text","label":"Who authorized these payments, state name and designation?","options":[],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if Yes, explain frequency and checker of counterfoils","type":"text","label":"Was the defaulting employee required to give printed receipts from a book with counterfoils? Yes No. If yes, how often were the counterfoils checked and by whom?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if Yes, explain frequency and checker of bank-books","type":"text","label":"Was any money paid into the Bank by defaulting employee? Yes No. If yes, how often were the Bank-books examined/reconciled and by whom?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"State any cash balance allowed with the employee","type":"text","label":"What balance, if any, was allowed to be kept in defaulting employee’s hands?","options":[],"required":null,"pdf_field":""},{"help":"Describe frequency and method of cash account verification","type":"text","label":"How often his Cash accounts were balanced and how was their accuracy checked?","options":[],"required":null,"pdf_field":""},{"help":"State frequency of direct account statements to customers","type":"text","label":"How often were accounts sent directly to customers independently of the employee?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. Claim involving Stocks","fields":[{"help":"Indicate Yes or No; if Yes, describe how stocks were handled","type":"text","label":"Did the employee have charge of stocks? Yes No. If yes, in what way did the stocks reach his hands?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if No, provide authorizer's name and designation","type":"text","label":"Was he allowed to issue stores/materials independently? Yes No. If not, who authorized these issues, state name and designation?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"State frequency and person responsible for stock checks","type":"text","label":"How often was the position of stocks handled by the defaulting employee checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Date of the most recent stock check","type":"date","label":"When was the last check made?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. General","fields":[{"help":"Provide audit frequency and auditor details","type":"text","label":"How often the Accounts Books/Stock Books at the place of defaulting employee’s employment were audited and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Date when last audit was conducted","type":"date","label":"Date of last audit","options":[],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if Yes, provide details","type":"text","label":"Was there a previous irregularity as regards defaulter’s work area? Yes No. If yes, state the details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if Yes, provide details and amounts","type":"text","label":"Has the insured any money (salary, remuneration, commission etc), estate or effects of the defaulting employee in his possession? Yes No. If yes, give details with amount.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if Yes, provide details and amounts","type":"text","label":"Does the insured hold any other security/guarantee from the defaulting employee? Yes No. If yes, give details and amount.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate Yes or No; if Yes, provide details","type":"text","label":"Is the defaulting employee member of a joint family or does he hold any property, furniture or other effects? Yes No. If yes, give details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List names and addresses of close relatives","type":"text","label":"Give names and addresses of employee’s near relatives.","options":[],"required":null,"pdf_field":""},{"help":"Describe any disciplinary or legal action taken","type":"text","label":"What action has been taken against the defaulting employee?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. Declaration","fields":[{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Affix company stamp","type":"text","label":"Company’s stamp","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Fidelity Guarantee Insurance policies","attachments":["Copy of FIR if the matter has been reported to Police"],"declarations":["The insured declares that no material information has been withheld and all statements are true to the best of their knowledge.","The articles/property described belong to the insured and no other person has interest except as mentioned in the policy.","The claim may be refused if information is untrue, inaccurate or concealed."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customercare@rahejaqbe.com","label":"Claims service mail ID","level":null,"hours":"Monday to Saturday, 9 am to 8 pm","applies_to":"all","source_url":"https://rahejaqbe.com/claims","quote":"Commercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolicy\nServicing\nLet us call you","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"info@mediassistindia.com","label":"Medi Assist TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.c","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashless@mediassist.in","label":"Medi Assist TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":", kindly visit\nhttps://www.medibuddy.in/claim\nToll Free Number :\n1800-4259-449\nEmail Address :\ninfo@mediassistindia.com\ncashless@mediassist.in\nCashless everywhere\nReimbursement claim registration :\nRetail\nCorp employee\nMedi Assist Insurance TPA Pvt. Ltd.\n4th Flo","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"contact.phs@paramounttpa.com","label":"Paramount TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"nonetwork.phs@paramounttpa.com","label":"Paramount TPA Non-network Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ttpa.com/PolicyClaim/PolyClaimStatus.aspx\nToll Free Number :\n9122-66620808\nEmail Address :\ncontact.phs@paramounttpa.com\nnonetwork.phs@paramounttpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nParamount TPA Office","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"assistance@volohealthtpa.com","label":"Volo Health TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ed (Annual Disclosure) – Disclosures Data (22-23)\nTPA Details\nVolo Health\nToll Free Number :\n1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimburse","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashlesseverywhere@volohealthtpa.com","label":"Volo Health TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"losures Data (22-23)\nTPA Details\nVolo Health\nToll Free Number :\n1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"support@volohealthtpa.com","label":"Volo Health TPA Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Surak","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashless@volohealthtpa.com","label":"Volo Health TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nVolo Health Insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customersupport@healthindiatpa.com","label":"HealthIndia Insurance TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Suraksha Bima\n,\nPravasi Bhartiya Bima Yoja","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"preauth@healthindiaindiatpa.com","label":"HealthIndia Insurance TPA Preauth Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"pa.com/CustomerCorner/ClaimStatus.aspx\nToll Free Number :\n1800220102\nEmail Address :\ncustomersupport@healthindiatpa.com\npreauth@healthindiaindiatpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nHealthIndia Insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"help@vidalhealthtpa.com","label":"Vidal Health Insurance TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"o@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Suraksha Bima\n,\nPravasi Bhartiya Bima Yojana\n,\nGroup Hospital Cash\n,","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@rahejaqbe.com","label":"Claims email for two wheeler bundled policy","level":null,"hours":null,"applies_to":"motor","source_url":"https://rahejaqbe.com/uploads/images/tw-bundle/pdf/download/tw-bundle-_Prospectus-V01.pdf","quote":"800-102-7723 or in writing at the nearest Offices or through an intermediary.\n• Alternatively, you can also reach us at claims@rahejaqbe.com You can report with vehicle/ report claim at network garage whereby claim registration shall be done by network garage","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001027723","label":"Claims call centre","level":null,"hours":"Monday to Saturday, 9 am to 8 pm","applies_to":"all","source_url":"https://rahejaqbe.com/claims","quote":"ims!\nExplore\nCommercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-4259-449","label":"Medi Assist TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"p Up\n,\nArogya Sanjeevani\n,\nGroup Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"9122-66620808","label":"Paramount TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"njeevani\n,\nGroup Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800202022","label":"Volo Health TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsuppor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800220102","label":"HealthIndia Insurance TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealtht","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"080-28004114/18004257878","label":"Vidal Health Insurance TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@he","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-102-7723","label":"Call centre for claims intimation","level":null,"hours":"9 am to 8 pm, Monday to Saturday","applies_to":"all","source_url":"https://rahejaqbe.com/uploads/images/two-wheeler-package/pdf/download/tw-package-prospectus-V01.pdf","quote":"ct numbers specified in the Schedule to the Policy.\n• Intimation of claim can also be made to Raheja QBE Call centre at 1800-102-7723 or in writing at the nearest Offices or through the intermediary.\n• Alternatively, you can also reach us at customercar","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/raheja-qbe-general-insurance/1061-claim-form-fidelity-guarantee-insurance"}