{"id":1083,"title":"Insolvency Liability Risk Insurance Policy CLAIM FORM","purpose":"claim","insurer":{"slug":"raheja-qbe-general-insurance","name":"Raheja QBE General Insurance Co. Ltd."},"source_pdf":"https://rahejaqbe.com/uploads/images/insolvency-liability-risk-insurance/pdf/download/insolvency-liability-risk-insurance-claim-form-V01.pdf","sha256":"f9b070d8886eb6c0a173a88492349f694af1a35d96eab1498db428a5bcae7bf4","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured policyholder to claim under the Insolvency Liability Risk Insurance policy for losses due to debtor insolvency or related risks.","notes":["If space is insufficient, attach separate sheets.","Use the currency unit elected for claims payment.","Provide copies of all requested documents; originals or photocopies are acceptable.","If more than 20 outstanding invoices, provide last 20 for initial assessment.","Attach ledger or statements covering 12 months prior to oldest unpaid invoice up to last transaction date."],"title":"Insolvency Liability Risk Insurance Policy CLAIM FORM","submit":{"to":"Raheja QBE General Insurance Company Limited","how":"post","address":"WING-A, 501-502, 5th Floor, Fulcrum, IA Project Rd, Sahar Village, Andheri East, Mumbai, Maharashtra 400059"},"purpose":"claim","sections":[{"title":"Your Claim - Details","fields":[{"help":"","type":"text","label":"Name of Insured. (or Joint Insured)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Your debtor’s name – Insured Buyer’s correct legal entity","options":[],"required":null,"pdf_field":""},{"help":"Provide registration number if applicable","type":"text","label":"Registration number (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Debtor’s industry","options":[],"required":null,"pdf_field":""},{"help":"Include postcode and country","type":"text","label":"Debtor’s address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Postcode","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Telephone","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Date when loss or insolvency occurred","type":"date","label":"Date of loss or insolvency of debtor","options":[],"required":null,"pdf_field":""},{"help":"Select one applicable type","type":"choice","label":"Type of loss or insolvency","options":["Insolvency","Protracted Default","Contract Repudiation","Political Risk"],"required":null,"pdf_field":""},{"help":"Explain reasons if claim is not insolvency","type":"text","label":"For non insolvency claims please provide details of the reasons for non payment","options":[],"required":false,"pdf_field":""},{"help":"Describe any disputes or complaints","type":"text","label":"Has the debtor raised any dispute or complaint in regard to the terms of the contract? If ‘Yes’, please give details","options":[],"required":false,"pdf_field":""},{"help":"State total amount owed, confirm currency","type":"amount","label":"Total amount owed by debtor [Please confirm if this amount is to be stated in INR]","options":[],"required":null,"pdf_field":""},{"help":"Currency in which policy is denominated","type":"text","label":"Policy Currency","options":[],"required":null,"pdf_field":""},{"help":"State amount claimed under policy terms","type":"amount","label":"Amount claimed under the Policy (please take into account the Permitted Limit, Insured Percentage and any items not covered by your Policy)","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"General Information","fields":[{"help":"Date when credit account was opened","type":"date","label":"Date account first opened on credit terms","options":[],"required":null,"pdf_field":""},{"help":"Specify payment terms agreed","type":"text","label":"Terms of Payment agreed with debtor (please be specific)","options":[],"required":null,"pdf_field":""},{"help":"Indicate if credit was approved under endorsement","type":"yes-no","label":"(a) Was credit approved under an Official Limit Endorsement? If ‘Yes’, provide copy of endorsement. If ‘No’, refer to (b)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details and copies of relevant reports if applicable","type":"text","label":"If ‘Yes’, was credit granted relying on: (i) Trading Experience (ii) Trade References (iii) Status Report/Trade Report (iv) Bank Report (v) Other—Please provide all pertinent details","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Information","fields":[{"help":"Describe actions taken and attach documents","type":"text","label":"What specific action, including legal action, was taken from the date the account became reportable to the date of insolvency, in pursuing the debtor for payment of the outstanding debt? Please provide all relevant copy documents.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of all unpaid invoices/credit notes","fields":[{"help":"List all unpaid invoices with these columns; attach copies of invoices and credit notes","type":"table","label":"Invoice number, Date of invoice, Date of Delivery or Work Done, Due Date for Payment, Gross invoice Value (incl. any sales tax), Currency of Invoice, Rate of Exchange used for conversion to Policy Currency for declaring, Turnover of Transactions, Sales tax, GST, Retention monies & Other Policy Exclusions","options":[],"required":null,"pdf_field":""},{"help":"Attach ledger or statements covering 12 months prior to oldest unpaid amount","type":"table","label":"Ledger reconciliation for the 12 month period prior to the oldest unpaid invoice: Month of invoice/Delivery/Work Done/Despatch, Total amount invoiced in the month (incl. GST), Date by which monthly amount cleared/paid, Days credit taken","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Supporting Documents","fields":[{"help":"","type":"checkbox","label":"The ORDER(S) relating to the outstanding invoices and your CONFIRMATION(S) of the order(s). Please send any evidence of the contract of sale","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"The OUTSTANDING INVOICE(S)","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"The statements of the account for the period commencing 12 months prior to the oldest unpaid invoice and up to the date of the last transaction","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"All relevant CORRESPONDENCE (especially all communications received from the buyer)","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"If the debtor is insolvent, any available EVIDENCE OF INSOLVENCY (for example, a notice from the Receiver or Liquidator)","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of the relevant CONDITIONS OF SALE","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Any NOTICES FROM YOUR BANK advising that payments due have been dishonoured","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Any outstanding BILL(S) OF EXCHANGE, PROMISSORY NOTES or DRAFTS","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"All BILL(S) OF LADING or AIRWAY BILL(S) relating to unpaid invoices","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration of Insured and Signature","fields":[{"help":"Name of person signing","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Position of signer in company","type":"text","label":"Position in company","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized person","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Space if required","fields":[{"help":"Use for any extra information","type":"text","label":"Additional Space if required","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":["Notify Raheja QBE as soon as possible after loss or damage becomes known","Submit claim form and documents at the earliest"],"applies_to":"Insolvency Liability Risk Insurance claims","attachments":["ORDER(S) relating to the outstanding invoices and your CONFIRMATION(S) of the order(s)","OUTSTANDING INVOICE(S)","Statements of the account for the period commencing 12 months prior to the oldest unpaid invoice and up to the date of the last transaction","All relevant CORRESPONDENCE (especially all communications received from the buyer)","If the debtor is insolvent, any available EVIDENCE OF INSOLVENCY (for example, a notice from the Receiver or Liquidator)","Copy of the relevant CONDITIONS OF SALE","Any NOTICES FROM YOUR BANK advising that payments due have been dishonoured","Any outstanding BILL(S) OF EXCHANGE, PROMISSORY NOTES or DRAFTS","All BILL(S) OF LADING or AIRWAY BILL(S) relating to unpaid invoices","Copies of all outstanding invoices (or last 20 if more than 20)","Copies of relevant credit notes","Ledger and/or statements covering all entries for the period commencing 12 months prior to the oldest unpaid amount up to and including the date of the last transaction"],"declarations":["The insured warrants the truth and completeness of the statements made in the claim form.","False or fraudulent statements or suppression of facts will result in forfeiture of the claim and policy being null and void.","The insured authorizes disclosure of interest in the account to the appropriate authority dealing with the debtor’s affairs.","The insured agrees to complete and submit an assignment of the debt to Raheja QBE if requested.","The insured will obtain or attach written confirmation from the Liquidator, Trustee, Receiver, or other authority of the amount admitted in the Insolvent Estate or evidence of debt."],"dropped_labels":1},"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/1083-insolvency-liability-risk-insurance-policy-claim-form"}