{"id":1149,"title":"BROAD FORM LIABILITY CLAIM FORM","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/f10f2db96a7740a399b4901bf3e91545.pdf","sha256":"a0a75ab7140db6001d3ba685a088f48e64bf845fdf2b74f6f5212cbaf0496b15","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to report and claim for a liability loss or accident under their insurance policy.","notes":["Please read the claim form fully before answering the questions.","All questions must be answered as fully as possible.","Use additional sheets if necessary.","Appointment of legal representatives should not occur without prior consent of the insurer.","In case of more than one injured/deceased person, provide individual details in a separate annexure.","Affix or staple the cancelled cheque in the NEFT payment form section."],"title":"BROAD FORM LIABILITY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured/Claimant","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"From and to dates","type":"date","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Retroactive date, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insured’s Business","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Last Premium Paid","options":[],"required":false,"pdf_field":""},{"help":"Specify limits as per policy","type":"text","label":"Limits of Liability under the policy","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss","fields":[{"help":"Date when the accident or incident occurred","type":"date","label":"Date of Loss","options":[],"required":true,"pdf_field":""},{"help":"Specify time and select A.M. or P.M.","type":"text","label":"Time of Loss","options":["A.M.","P.M."],"required":true,"pdf_field":""},{"help":"Describe the accident fully; use back of form if needed","type":"text","label":"How did accident / incident occur? Give full details and description on back of form illustrated by rough sketch if necessary","options":[],"required":true,"pdf_field":""},{"help":"Full address where accident happened","type":"text","label":"Place Accident Occurred with full address details","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the cause of accident attributable to negligence of any of your employee/s","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Occupation of negligent employee","type":"text","label":"If ‘Yes’, Occupation","options":[],"required":false,"pdf_field":""},{"help":"Name of negligent employee","type":"text","label":"If ‘Yes’, Name","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the cause of accident attributable to any person NOT in your employ","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Occupation of person not employed by you","type":"text","label":"If ‘Yes’, Occupation","options":[],"required":false,"pdf_field":""},{"help":"Name of person not employed by you","type":"text","label":"If ‘Yes’, Name","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the cause of accident attributable to work being carried out under contract","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of indemnity or disclaimer if any","type":"text","label":"If ‘Yes’, Has any indemnity or disclaim been given or received, pl. provide details","options":[],"required":false,"pdf_field":""},{"help":"Describe the negligent act","type":"text","label":"Detail act of negligence","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Other Insurance/Interest","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Is the cause of accident attributable to any defect in your ways, works, machinery, plant or premises?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe the defect","type":"text","label":"If ‘Yes’, Please state exact nature of defect","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Were there any witnesses to the loss / accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name(s) of witnesses","type":"text","label":"If ‘Yes’, Name of Person/s","options":[],"required":false,"pdf_field":""},{"help":"Address of witnesses","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"City of witnesses","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"State of witnesses","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Pin code of witnesses","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Phone number of witnesses","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of witnesses","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Email ID of witnesses","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the loss been reported to an Authority","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of authority where loss was reported","type":"text","label":"Name of Authority","options":[],"required":false,"pdf_field":""},{"help":"Reference number given by authority","type":"text","label":"Authority Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Contact person at authority","type":"text","label":"Contact Person/s","options":[],"required":false,"pdf_field":""},{"help":"Address of authority","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"City of authority","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"State of authority","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Pin code of authority","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Phone number of authority","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of authority","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Email ID of authority","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the loss/damage covered under any other Insurance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of other insurance","type":"text","label":"If ‘Yes’, specify details and attach a copy of the policy","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"Address of other insurer","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Period of other insurance","type":"date","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other insurance","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"The Injured / Deceased Person","fields":[{"help":"Full name and address","type":"text","label":"Name and address of Injured/deceased","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Address of injured/deceased","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"City of injured/deceased","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of injured/deceased","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Pin code of injured/deceased","type":"number","label":"PinCode","options":[],"required":true,"pdf_field":""},{"help":"Phone number of injured/deceased","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of injured/deceased","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Occupation or work nature","type":"text","label":"State occupation / nature of work of the injured person","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Was the Injured/deceased person engaged in this occupation when the accident occurred?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe work if different","type":"text","label":"If “No”, state exactly the nature of the work he/she was doing at the time of accident","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Injured/deceased person in your direct employment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe injury and affected body part","type":"text","label":"State nature of injury & part of body affected","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is there disablement?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select type of disablement","type":"choice","label":"If “Yes” select","options":["Total","Partial","Permanent","Temporary"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the disability solely caused by this accident / Incident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain other causes if any","type":"text","label":"If “No”, give details","options":[],"required":false,"pdf_field":""},{"help":"Number of days","type":"number","label":"How long is the disablement expected to last?","options":[],"required":false,"pdf_field":""},{"help":"Expected end date of disablement","type":"date","label":"Upto","options":[],"required":false,"pdf_field":""},{"help":"Percentage of disability","type":"number","label":"Extent of disability","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Was the injured person under the influence of alcohol or drugs at the time of accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Current health status","type":"text","label":"Present health condition","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"In event of Death: Post Mortem Done","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Date post mortem was done","type":"date","label":"Date of PM Done","options":[],"required":false,"pdf_field":""},{"help":"Post mortem number","type":"text","label":"PM No.","options":[],"required":false,"pdf_field":""},{"help":"Hospital details","type":"text","label":"Name and address of Hospital where Post mortem has been done","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Damage Details","fields":[{"help":"Owner details","type":"text","label":"Name and address of the owner of damaged property","options":[],"required":true,"pdf_field":""},{"help":"Describe damage","type":"text","label":"Nature and extent of damaged property","options":[],"required":true,"pdf_field":""},{"help":"Estimated repair cost in Rs.","type":"amount","label":"Estimated Cost of Repair","options":[],"required":true,"pdf_field":""},{"help":"Legal basis for liability","type":"text","label":"Give the details of Statute/ Law under which in your opinion liability may arise","options":[],"required":false,"pdf_field":""},{"help":"Describe accident fully; include sketch if possible","type":"text","label":"Give Full Details of the Accident including a sketch, if possible","options":[],"required":true,"pdf_field":""},{"help":"Describe any relationship","type":"text","label":"Any Relationship between you and the injured ?","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have the Injured/deceased persons been taken to hospital or medically attended?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"If “Yes”, specify Name of Hospital / Physician","options":[],"required":false,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"NEFT – Electronic Fund Transfer - Payment Form – For Claims Disbursement","fields":[{"help":"Name as per bank account","type":"text","label":"Full Name (As appears in your Policy/Bank account)","options":[],"required":true,"pdf_field":""},{"help":"Mobile contact number","type":"phone","label":"Contact no.(M)","options":[],"required":false,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Address of bank branch","type":"text","label":"Bank Address","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No.","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC code","options":[],"required":true,"pdf_field":""},{"help":"MICR code of bank branch","type":"text","label":"MICR CODE","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration and Signature","fields":[{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature and company seal","type":"signature","label":"Insured’s Signature with Company Seal","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":["Please send the completed claim form, as soon as possible to us"],"applies_to":"","attachments":["copies of relevant documentation","copy of the other insurance policy if applicable","cancelled cheque for NEFT payment"],"declarations":["The insured warrants the truth of the statements made in the form to the best of their knowledge and belief.","If any false or fraudulent statement, suppression or concealment is made, the claim shall be forfeited and the policy null and void."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customer.care@sbigeneral.in","label":"Motor Claims Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"m\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journeys, always\nDownload SBIG App\nRegister or Tra","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"sbig.health@sbigeneral.in","label":"Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"ailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th Floor, Westport, Pan Card","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcitizen.health@sbigeneral.in","label":"Senior Citizen Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 1111","label":"Motor Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"e Claim\nFAQs\nDownload Claim Form\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journ","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 3366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"e simple click\nCheck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 6366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"heck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"sms","value":"561612","label":"Health Claims SMS 'HEALTHCLAIM'","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"y Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office","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/sbi-general-insurance/1149-broad-form-liability-claim-form"}