{"id":2258,"title":"Bharat Yatra Suraksha Group, Liberty General Insurance Limited Claim Form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Bharat%20Yatra%20Suraksha%20Group%20-%20Claim%20Form.pdf","sha256":"f4e608993d6d90b5f6c0ed2f52937c721e2e2332aef5426450b5c16ec1095513","pages":12,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant to request reimbursement for various benefits under the Bharat Yatra Suraksha Group insurance policy issued by Liberty General Insurance Limited.","notes":["Issuance of this form does not amount to admission of liability or waiver of policy terms and conditions.","Please give information correctly and completely to enable prompt claim processing.","Use additional sheet if required.","Refer Annexure A for documents to be submitted in support of the claim.","Original bills and receipts are required.","KYC documents required if claim liability is above Rs 1 Lakh as per AML guidelines.","For loss of checked baggage, an undertaking is required stating refund of claim if baggage is returned.","For trip delay, carrier confirmation of delay is mandatory.","Use block letters where applicable."],"title":"Bharat Yatra Suraksha Group, Liberty General Insurance Limited Claim Form","submit":{"to":"Corporate Office: Liberty General Insurance Ltd. 10th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel - 400013.","how":"post","address":"Liberty General Insurance Ltd. 10th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel - 400013."},"purpose":"claim","sections":[{"title":"Policy and Claimant Details","fields":[{"help":"Enter the master policy number as per your insurance documents.","type":"text","label":"Master Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the policyholder.","type":"text","label":"Policy Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the person making the claim.","type":"text","label":"Claimant’s Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the certificate number of insurance.","type":"text","label":"Certificate of Insurance No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the claimant.","type":"text","label":"Claimant’s Address","options":[],"required":null,"pdf_field":""},{"help":"Enter the claimant's mobile phone number.","type":"phone","label":"Phone No. (Mobile)","options":[],"required":null,"pdf_field":""},{"help":"Enter the claimant's residential phone number, if available.","type":"phone","label":"Phone No. (Res)","options":[],"required":false,"pdf_field":""},{"help":"Enter the claimant's email address.","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter the policy start date in DDMMYYYY format.","type":"date","label":"Policy start date","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy end date in DDMMYYYY format.","type":"date","label":"Policy end date","options":[],"required":null,"pdf_field":""},{"help":"Tick 'Y' or 'N' for each coverage opted and fill claimed amount if applicable.","type":"table","label":"Please tick the applicable benefit You want to claim for: (If Opted and Available)?","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Expenses due to Accident","fields":[{"help":"Enter full details of the hospital or clinic where treatment was received.","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic","options":[],"required":null,"pdf_field":""},{"help":"Enter the name and qualifications of the treating doctor.","type":"text","label":"Treating Doctor's Name & Qualifications","options":[],"required":null,"pdf_field":""},{"help":"Office phone number of the treating doctor.","type":"phone","label":"Treating Doctor's Telephone Number: (O)","options":[],"required":false,"pdf_field":""},{"help":"Enter the room, ward or bed number where the patient was admitted.","type":"text","label":"Room / Ward / Bed Number","options":[],"required":false,"pdf_field":""},{"help":"Enter the start date of treatment in DDMMYYYY format.","type":"date","label":"Dates of treatment: From","options":[],"required":null,"pdf_field":""},{"help":"Enter the date symptoms first appeared in DDMMYYYY format.","type":"date","label":"Date of onset of symptoms","options":[],"required":null,"pdf_field":""},{"help":"Enter the date the doctor was contacted in DDMMYYYY format.","type":"date","label":"Date doctor contacted","options":[],"required":null,"pdf_field":""},{"help":"Enter the time doctor was contacted in HHMM format.","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Describe the nature of the ailment.","type":"text","label":"Nature of Ailment","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis and treatment details.","type":"text","label":"State diagnosis and nature of treatment provided","options":[],"required":null,"pdf_field":""},{"help":"Provide the date or description of symptom onset.","type":"text","label":"When did patient's symptoms first appear?","options":[],"required":null,"pdf_field":""},{"help":"Mention any other diseases affecting the condition.","type":"text","label":"Describe any other disease or infirmity affecting present condition","options":[],"required":false,"pdf_field":""},{"help":"Tick if the ailment was due to pregnancy.","type":"yes-no","label":"Was the ailment due to Pregnancy","options":["No"],"required":null,"pdf_field":""},{"help":"Tick if the ailment was aggravated by pre-existing condition.","type":"yes-no","label":"Was the ailment aggravated due to any pre-existing condition?","options":["No"],"required":null,"pdf_field":""},{"help":"Provide details if pre-existing condition aggravated the ailment.","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if patient can be evacuated for treatment.","type":"yes-no","label":"Can the patient be evacuated to another location for Treatment?","options":["No"],"required":null,"pdf_field":""},{"help":"Doctor to sign and date the form.","type":"signature","label":"Medical Doctor's Signature and Date","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Accident & Disability Related","fields":[{"help":"Enter the date of the accident in DDMMYYYY format.","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter the time of accident.","type":"text","label":"Time of Accident","options":[],"required":false,"pdf_field":""},{"help":"Enter the place and location of the accident.","type":"text","label":"Place & Location","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident or incident in detail.","type":"text","label":"Description of accident/Incidence","options":[],"required":null,"pdf_field":""},{"help":"List the injuries sustained in the accident.","type":"text","label":"Details of injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"Specify if disability is permanent or partial.","type":"text","label":"Nature of Disability (Permanent/Partial)","options":[],"required":null,"pdf_field":""},{"help":"Enter the percentage of disability.","type":"number","label":"Percentage of Disability","options":[],"required":false,"pdf_field":""},{"help":"Indicate if disability certificate was issued.","type":"yes-no","label":"Disability Certificate Issued","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if X-ray was taken.","type":"yes-no","label":"X-ray taken","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide diagnosis and treatment details.","type":"text","label":"Diagnosis and Treatment given","options":[],"required":false,"pdf_field":""},{"help":"Doctor to sign here.","type":"signature","label":"Signature: Attending Doctor’s Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Loss of Checked-In Baggage","fields":[{"help":"Describe the circumstances of baggage loss or delay.","type":"text","label":"Describe when & where the Loss / Delay took place","options":[],"required":null,"pdf_field":""},{"help":"Describe the extent of loss or delay.","type":"text","label":"State the extent of Delay / Loss","options":[],"required":null,"pdf_field":""},{"help":"Enter the place where delay or loss occurred.","type":"text","label":"Place of Delay / Loss","options":[],"required":null,"pdf_field":""},{"help":"Enter date and time when bags were delivered.","type":"date","label":"Actual Date & Time when Bags were delivered","options":[],"required":false,"pdf_field":""},{"help":"Indicate if carrier was notified at time of loss.","type":"yes-no","label":"Had the common carrier been notified at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the PIR number obtained from airline.","type":"text","label":"Property Irregularity Report (PIR) number from Airline/ Common Carrier","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any compensation received.","type":"text","label":"Details of compensation received from carrier","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Trip Cancellation and Interruption","fields":[{"help":"Select whether trip was cancelled or interrupted.","type":"choice","label":"Trip cancelled / Trip Interruption","options":["Trip cancelled","Trip Interruption"],"required":null,"pdf_field":""},{"help":"Explain the reason for cancellation or interruption.","type":"text","label":"Reason for Trip Cancellation / Interruption","options":[],"required":null,"pdf_field":""},{"help":"List items lost or purchased with dates and costs.","type":"table","label":"Sr. No., Item Purchased / Items Lost, Date of Purchase, Cost in INR for loss claim (table)","options":[],"required":false,"pdf_field":""},{"help":"Provide detailed explanation of trip cancellation or curtailment.","type":"text","label":"Please detail out the above reason for trip cancellation / Curtailment (how, where, when and reason for the same)","options":[],"required":false,"pdf_field":""},{"help":"Enter the date of cancellation or interruption.","type":"date","label":"Trip Cancellation / Interruption date","options":[],"required":false,"pdf_field":""},{"help":"Enter original travel start date.","type":"date","label":"Original Travel Dates: From","options":[],"required":false,"pdf_field":""},{"help":"Provide details of person affected if not the insured.","type":"text","label":"Person Affected and Relationship with the Insured","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Trip Delay","fields":[{"help":"Explain the reason for trip delay.","type":"text","label":"Reason for Trip Delay","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed explanation of trip delay.","type":"text","label":"Please detail out the reason for trip delay (how, where, when, what was lost and reason for the same)","options":[],"required":false,"pdf_field":""},{"help":"Enter original travel start date.","type":"date","label":"Original Travel Dates: From","options":[],"required":false,"pdf_field":""},{"help":"Enter the date when trip was delayed.","type":"date","label":"Trip delayed on","options":[],"required":false,"pdf_field":""},{"help":"Provide details of person affected if not the insured.","type":"text","label":"Person Affected and Relationship with the Insured","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Compassionate Allowance","fields":[{"help":"Select the type of compassionate allowance claimed.","type":"choice","label":"Emergency Family Visit / Emergency Family Accommodation","options":["Emergency Family Visit","Emergency Family Accommodation"],"required":null,"pdf_field":""},{"help":"Enter hospital or clinic details.","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic","options":[],"required":null,"pdf_field":""},{"help":"Enter treating doctor's name and qualifications.","type":"text","label":"Treating Doctor's Name & Qualifications","options":[],"required":null,"pdf_field":""},{"help":"Office phone number of treating doctor.","type":"phone","label":"Treating Doctor's Telephone Number: (O)","options":[],"required":false,"pdf_field":""},{"help":"Room or bed number of patient.","type":"text","label":"Room / Ward / Bed Number","options":[],"required":false,"pdf_field":""},{"help":"Hospitalization start date.","type":"date","label":"Dates of hospitalization: From","options":[],"required":null,"pdf_field":""},{"help":"Date symptoms began.","type":"date","label":"Date of onset of symptoms","options":[],"required":null,"pdf_field":""},{"help":"Date doctor was contacted.","type":"date","label":"Date doctor contacted","options":[],"required":null,"pdf_field":""},{"help":"Time doctor was contacted.","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Describe the ailment.","type":"text","label":"Nature of Ailment","options":[],"required":null,"pdf_field":""},{"help":"Diagnosis and treatment details.","type":"text","label":"State diagnosis and nature of treatment provided","options":[],"required":null,"pdf_field":""},{"help":"Date or description of symptom onset.","type":"text","label":"When did symptoms first appear?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if ailment was due to pregnancy.","type":"yes-no","label":"Was the ailment due to Pregnancy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if pre-existing condition aggravated ailment.","type":"yes-no","label":"Was the ailment aggravated due to any pre-existing condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if patient can be evacuated back.","type":"yes-no","label":"Can the patient be evacuated back to city of residence?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Estimate duration of hospital stay.","type":"text","label":"Estimated time the patient would continue to be in the hospital?","options":[],"required":false,"pdf_field":""},{"help":"Doctor to sign and date.","type":"signature","label":"Medical Doctor's Signature and Date","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Missed Flight Connection","fields":[{"help":"Provide dates, times, carriers and flight numbers of all flights.","type":"text","label":"Original Travel Schedule","options":[],"required":null,"pdf_field":""},{"help":"Specify the delayed flight.","type":"text","label":"Which flight was delayed causing a missed connection?","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for flight delay.","type":"text","label":"Reason for delay of the flight","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Repatriation of Mortal Remains","fields":[{"help":"Provide details of carrier and flight used for repatriation.","type":"text","label":"Common carrier/flight details","options":[],"required":false,"pdf_field":""},{"help":"List expenses and amounts for preparation and packing.","type":"table","label":"Details of expenses preparation and packing of the mortal remains (table)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Automatic Trip Extension","fields":[{"help":"Provide carrier and flight details for trip extension.","type":"text","label":"Common carrier/flight details","options":[],"required":false,"pdf_field":""},{"help":"Enter travel or flight date.","type":"date","label":"Travel date/Flight date","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Carrier Cancellation (applicable only for air travel)","fields":[{"help":"Provide details of carrier and flight cancelled.","type":"text","label":"Common carrier/flight details","options":[],"required":false,"pdf_field":""},{"help":"Enter travel or flight date.","type":"date","label":"Travel date/Flight date","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration","fields":[{"help":"Enter place of signing.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Claimant must sign here.","type":"signature","label":"Signature of the claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Claims under Bharat Yatra Suraksha Group insurance policy for benefits such as hospitalization expenses due to accident, accidental death, disability, trip delay, trip cancellation, loss of checked-in baggage, compassionate allowance, missed flight connection, repatriation of mortal remains, automatic trip extension, and carrier cancellation.","attachments":["Duly completed claim form","Photo Identity Proof of the insured person","Any other relevant document required by the Company for assessment of the claim","NEFT Details and cancelled cheque","KYC (Identity proof with Address) of the proposer if claim liability is above Rs 1 Lakh","Original Discharge Summary (wherever applicable)","Original Medical Reports","Original Invoices/Bills","Original Payment Receipts","Investigation Reports supporting the diagnosis, if any","Treating doctors report for necessity for evacuation, if applicable","Death Certificate","Post-mortem Certificate, if conducted","FIR (wherever required)","Police Investigation report","Viscera Sample Report (if applicable)","Forensic Laboratory report","Legal Heir Certificate","Succession Certificate","Copy of discharge summary (if available)","Original treating Medical Practitioner's certificate confirming the disability and its %","Original Discharge summary from the Hospital","Any other medical, investigation reports, inpatient or consultation treatment papers, as applicable","Receipt for expenses incurred towards preparation and packing of the mortal remains","Copy of Embalming certificate, if any","Flight itinerary and Boarding pass and/or ticket details as applicable","Copy of death certificate","Post mortem report, if conducted","Certificate from common carrier on cancellation of flight","Newspaper articles, if any","Report from the treating doctor advising the requirement of support from family or any person deputed by the family","Copy of the ticket","Copy of the receipt for accommodation","Copies of Travel ticket and boarding pass of flight Scheduled from the first port of arrival","Confirmation from the Common Carrier of the delayed flight along with the reasons for delay","Unused ticket for the ongoing flight (Missed Flight)","Original used ticket obtained afresh towards the alternative flight","Certificate from the Common Carrier of the Missed Flight that the fare for the part of the Trip covered by the Missed Flight is forfeited in full or in part together with the amount of forfeiture","Common Carrier for the part of the journey covered by the missed Common Carrier indicating the amount paid as fare, and in which such Insured Person has travelled","Confirmation of the delay from the Common Carrier which is used for transit to the Place of Origin of the booked journey as to the scheduled ETA and the actual time of arrival at Place of Origin","Copies of correspondence with airline authorities / others about loss of checked baggage, along with details of compensation received from airlines / other authorities (if any)","Property Irregularity Report (obtained from airline)","Undertaking in writing stating that if baggage is traced and returned, the claimant will refund the entire claim amount settled","Flight itinerary","Copy of ticket & boarding pass","Certificate from the Common Carrier confirming the delay and detailing the circumstances of delay","Copies of correspondence with airline authorities certifying the delay, along with details of compensation received from airlines / other authorities (if any)","Confirmation from the Common Carrier of the cancellation of flight along with the reasons for cancellation","Confirmation of cancellation of the Trip detailing the circumstances of cancellation","Original ticket issued by the Common Carrier indicating the cost the ticket and receipt for the refund of the fare of the Common Carrier towards the cancelled portion of the Trip","Original bill and a receipt / letter obtained from the hotel and / or guest house and / or any other paid residential accommodation indicating the amount paid, refund given and cancellation charges retained","Ticket issued by the Common Carrier in original for return journey from the place of cancellation to the City of Residence or Place of Origin of the Insured indicating cost and receipts for refunds","Declaration from the Insured furnishing the circumstances that compelled cancellation (if due to personal contingencies)","Medical evidence as required by TPA in case of cancellation due to personal contingencies","Receipt for refund of fare indicating cancellation charges retained","Any other document as may be appropriately applicable for the claims"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim reimbursement shall be forfeited.","Consent and authorize insurance company to seek necessary medical information/documents from any hospital or medical practitioner who attended the person against whom this claim is made.","Consent TPA/Insurance company to share claim related information/documents to any third party agency or service provider for claim related enquiry/transaction only.","Declare that all bills/receipts for this claim are included and no supplementary claim will be made except pre/post-hospitalization claim, if any."],"dropped_labels":11},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/liberty-general-insurance/2258-bharat-yatra-suraksha-group-liberty-general-insurance-limited-claim-form"}