{"id":2269,"title":"LIBERTY COMPLETE PROTECT GROUP POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Complete%20Protect%20Group%20Policy_Claim%20Form.pdf","sha256":"cb85813ba24467397c4883b22cfe002bc3edb96ea19a27e1d1eb9b34ae27ba41","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the Liberty Complete Protect Group insurance policy for various benefits including hospital cash, personal accident, critical illness, vector borne diseases, EMI protector, and loan protector benefits.","notes":["To be filled in block letters.","Attach original reauthorization request form in lieu of PART A Section A Hospital Details.","Use separate sheet for additional bills or receipt details.","The issue of this form is not an admission of liability.","Photo ID and address proof are required for the insured or beneficiary in whose name payment is to be made.","NEFT mandate form must be filled by the person in whose name payment is to be done.","For police reported cases, attach FIR/MLC and related documents.","For group policies, HR certificates may be required.","Use original bills and documents as specified in the checklist.","Signatures and seals are required from the insured, hospital authority, and treating doctor as applicable."],"title":"LIBERTY COMPLETE PROTECT GROUP POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Basic Information","fields":[{"help":"","type":"text","label":"Policy Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Certificate No/Claim No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured Person Name 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format","type":"date","label":"DOB:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Accident Details","fields":[{"help":"dd mm yyyy","type":"date","label":"Date of Accident / hospitalization / Loss","options":[],"required":null,"pdf_field":""},{"help":"hh mm ss","type":"text","label":"Time of Accident / hospitalization / Loss","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place & Location :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Description of accident/Incidence :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Specify injured parts of the body","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Please specify nature of Disability","options":[],"required":null,"pdf_field":""},{"help":"Disability percentage","type":"number","label":"Please mention Disability percentage in case of permanent partial disablement, certified by Doctor %","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Witnesses","fields":[{"help":"","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact No : Residence :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Office :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile :","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section Claimed For","fields":[{"help":"Tick if claiming this section","type":"checkbox","label":"Section I - Daily Hospital Cash Benefit","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claiming this section","type":"checkbox","label":"Section II - Personal Accident Benefit","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claiming this section","type":"checkbox","label":"Section III - Critical Illness Benefit","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claiming this section","type":"checkbox","label":"Section IV - Vector Borne Diseases Benefit","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claiming this section","type":"checkbox","label":"Section V - EMI Protector Benefit","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claiming this section","type":"checkbox","label":"Section VI - Loan Protector Benefit","options":["Yes"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Treatment Details","fields":[{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Tel Nos:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Family Doctor : Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Tel Nos:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital Details : Name 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Disease First Diagnosed:","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Select one if injury","type":"choice","label":"If Injury, give cause :","options":["Self-Inflicted","Road Traffic Accident","Substance Abuse or Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"If Medico legal :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"MLC Report or Police FIR Attached :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of Benefit Claimed :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of 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Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Issuing Office","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Primary Insureds / Nominees Bank Account","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN No. :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Account Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Name / Branch :","options":[],"required":null,"pdf_field":""},{"help":"Name of account holder","type":"text","label":"Payable To :","options":[],"required":null,"pdf_field":""},{"help":"Indian Financial System Code","type":"text","label":"IFSC Code 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:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Additional Diagnosis :","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Hospital Section B - Details of Hospital","fields":[{"help":"","type":"text","label":"Hospital ID :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of Hospital :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the treating Doctor :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"","type":"signature","label":"SEAL & SIGNATURE OF THE HOSPITAL AUTHORITY","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place :","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Attending Physician Statement","fields":[{"help":"","type":"text","label":"Name & Age of the Insured Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nature of the Accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of the Injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Cause of Accident as stated by the Claimant tally with the Injuries noticed by you?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are the injuries solely due to the accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If No, Please provide the details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person suffering from any disease or injury which may have contributed to the accident or likely to aggravate his condition","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Was the claimant hospitalized? If so for what period? From","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What treatment was given and operations performed?","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Give all dates of treatment: Clinic Hospital: From","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Home: From","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was he / she under the influence of intoxicants or drugs at the time of accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you his family doctor?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Please give the details, If you have treated him for an previous illness or injury?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have other Doctors been in Attendance or Consultation?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, Please give the details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Has this accident been reported to the Police Authorities?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Police Station","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is this claimant Totally Disabled from each and every occupation?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"How long was or will the claimant be totally disabled from current occupation? From","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"How long was or will the claimant be partially disabled from current occupation? From","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"dd mm yyyy","type":"date","label":"Estimated date of return to Work Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What is the Prognosis?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Doctor's Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Tel No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"Claims under Liberty Complete Protect Group Policy including Daily Hospital Cash Benefit, Personal Accident Benefit, Critical Illness Benefit, Vector Borne Diseases Benefit, EMI Protector Benefit, Loan Protector Benefit","attachments":["Separate sheet for additional bills / receipt details","Copy of discharge summary/ Final bill/ investigation reports","Photo ID proof of the insured member whose name the payment is to be done","Address proof of the insured member whose name the payment is to be done","NEFT mandate form filled by deceased / Insured Person in whose name the payment is to be done","Indoor case papers from hospital","FIR / MLC from police authorities (for Personal Accident claims)","Driving License of the Insured Person in case death or injury because of Road Traffic accident","Death Certificate issued by competent Authorities","Death Summary from the Hospital Authorities if death is confirmed by the Hospital","Post Mortem Report if conducted","Inquest / Panchnama Report","Letter from HR stating the attendance closure to the incident (for Group policies)","Indemnity Bond / Succession Certificate/ Legal Heir Certificate","Latest Photograph of the beneficiary / Insured Person / Legal Heirs","Medical Certificate from the attending Medical Practitioner for the injury indicating the extent of disability","Hospital / Nursing Home Medical Records","Radiological / X Ray report relevant to the disability","Photographs of the insured showing affected area","Disability Certificate from Civil Surgeon in PPD & PTD Claim","Medical fitness certificate from the Treating consultant indicating duration of rest medically advised","Leave certificate from HR (for salaried people) if employee for Group policies","Salary certificate / income proof if employee for Group policies","Proof of number of dependent child /children viz. Ration card","Age proof of the dependent child /children","Proof of education and payment of fee","Certificate from treating doctor about the diagnosis and line of treatment given during hospitalization/medical treatment","Bills and receipts towards medical expenses","Copy of the test reports","Bills and receipt towards cost of transportation of the mortal remains","Bills and receipt towards expenses relevant to funeral ceremony","Bills and receipt towards cost of ambulance services","Permanent Total Disability / Permanent Partial Disability related documents","Bills and receipts towards vehicle or residence modifications","Certificate from the Bank stating the amortization schedule, the EMI Amounts, Principal Outstanding, etc.","Certificate from the employer of the Insured Person confirming termination, dismissal, suspension or retrenchment","Photo Id & Address Proof of insured member"],"declarations":["The claimant agrees to provide additional information if required and warrants the truthfulness of the statements made.","False or fraudulent statements or concealment of facts will void the policy and forfeit claim rights.","Consent is given to Liberty General Insurance Ltd. to approach doctors for necessary information.","Consent is given to process and share personal information with group companies or service providers for insurance and related products.","Hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","Attending physician certifies the accuracy of medical details and accident information."],"dropped_labels":2},"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/2269-liberty-complete-protect-group-policy-claim-form"}