{"id":2268,"title":"Liberty Surro Assure Policy Claim Form - Part A","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Surro%20Assure%20%E2%80%93%20Claim%20Form.pdf","sha256":"25048e00b1cc6bc7b9d6ce9d20129684224838370c86f53db9c42afc40133dd7","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under the Liberty Surro Assure Policy. The insured person fills Part A of the form.","notes":["Use block letters to fill the form.","If ABHA ID is not available, visit https://abdm.gov.in/ to create one and inform the insurer once created.","Attach original bills and receipts as listed in the checklist.","For details on filling each section, refer to the guidance on pages 5 and 6.","Part B of the claim form is to be filled by the hospital and is not for the insured person."],"title":"Liberty Surro Assure Policy Claim Form - Part A","submit":{"to":"Liberty General Insurance Limited","how":"","address":"Unit 1501&1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai – 400013"},"purpose":"claim","sections":[{"title":"Section A - Details of Primary Insured","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as allotted by IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID no","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the full postal address including street, city, and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"If ABHA ID is not available, visit https://abdm.gov.in/ to create one and inform once created","type":"text","label":"ABHA Id","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section B - Details of Insurance History","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Currently Covered by any other Mediclaim / Health Insurance?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If YES, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number as allotted by the insurance company","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Enter total sum insured as per the policy in rupees","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last four years since the inception of the contract?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Use mm yy format","type":"date","label":"Date of Hospitalization","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Previously covered by any other Mediclaim / Health Insurance","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If Yes company name","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section C - Details of Insured Person Hospitalized","fields":[{"help":"Enter full name of the patient (Surname, First name, Middle name)","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender","options":["Female","Male"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Relationship of Primary Insured","options":["Surrogate Mother","Oocyte Donor","Other"],"required":null,"pdf_field":""},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Enter full postal address including street, city, and pin code","type":"text","label":"Address (If different from above)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"If ABHA ID is not available, visit https://abdm.gov.in/ to create one and inform once created","type":"text","label":"ABHA Id","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D - Details of Hospitalization","fields":[{"help":"Enter full name of the hospital","type":"text","label":"Name of the Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate room category","type":"choice","label":"Room Category Occupied","options":["Day care","Single occupancy","Twin sharing","3 or more"],"required":null,"pdf_field":""},{"help":"Tick the appropriate reason","type":"choice","label":"Hospitalization due to","options":["Illness","Injury","Maternity"],"required":null,"pdf_field":""},{"help":"Use DD MM YYYY format","type":"date","label":"Date of Injury / Disease first detected / Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Use DD MM YY format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use HH MM format","type":"text","label":"Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use DD MM YY format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use HH MM format","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate cause","type":"choice","label":"If injury, give cause","options":["Self Inflicted","Road Traffic Accident","Substance Abuse or Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to Police","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC report or Police FIR attached","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Enter the system of medicine followed in treating the patient","type":"text","label":"System of medicine","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E - Details of Claim","fields":[{"help":"Enter amount claimed in rupees (do not enter paise)","type":"amount","label":"Hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Ambulance Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Others (Code)","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount claimed in rupees","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Surgical cash","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Convalescence","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Other","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount claimed in rupees","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section G - Details of Primary Insured's Bank Account","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax department","type":"text","label":"PAN No","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of bank and branch","type":"text","label":"Bank Name/ Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary to whom cheque/DD should be made out","type":"text","label":"Payable details: Cheque/ DD/NEFT* Payable to","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Declaration by the Insured","fields":[{"help":"Enter date of signing the declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"Health insurance claims under Liberty Surro Assure Policy","attachments":["Copy of the Claim Intimation, if any","Hospital Main Bill","Hospital Break Up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theater Notes","ECG","Doctor’s request for investigation","Investigation Reports (Including CT/MRI/USG/HPE)","Doctor’s Prescription","Others"],"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 TPA/insurance company to seek necessary medical information/documents from any hospital/medical practitioner who attended the person against whom this claim is made.","I have included all bills/receipts for this claim and will not make any supplementary claim except pre/post-hospitalization claim, if any.","I give voluntary consent to Liberty General Insurance Limited to process/share my personal information and data with group companies or service providers in connection with the insurance policy or claims."],"dropped_labels":3},"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/2268-liberty-surro-assure-policy-claim-form-part-a"}