{"id":2275,"title":"Liberty Group Personal Accident Policy Claim Form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/GPA%20Claim%20Form.pdf","sha256":"dc19f4ffc8d680dd8344fd08d891b6126df19eb03300ff4559fafbface5d0eaa","pages":15,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the Liberty Group Personal Accident Policy. It collects details about the insured, hospitalization, claim, and supporting documents.","notes":["Use block letters to fill the form.","Attach original bills and receipts only.","Submit all required documents as per the checklist relevant to the claim type.","The issue of the form is not an admission of liability.","For domiciliary hospitalization claims, provide details on annexure.","For non-network hospital claims, fill additional hospital details section.","Date formats: dd mm yy or dd mm yyyy as specified; time formats: hh mm.","For disability claims, provide medical certificates and photographs showing affected area.","For death claims, provide FIR, death certificate, post mortem report, legal heir certificate, and other documents as applicable.","For claims under other covers, provide specific proofs and bills as listed.","The hospital must include original preauthorization request form in lieu of Part A.","The hospital authority must sign and seal the hospital section.","The attending physician must complete the physician statement section and sign with seal."],"title":"Liberty Group Personal Accident Policy Claim Form","submit":{"to":"","how":"","address":""},"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 social insurance or certificate number if any","type":"text","label":"SL No / Certificate No/ Claim Number (If any)","options":[],"required":false,"pdf_field":""},{"help":"Enter TPA ID number as allotted by IRDA","type":"text","label":"Company/ TPA ID no","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address including street, city, and pin code","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":"","type":"text","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email 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":true,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"Date of commencement of first Insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of insurance company","type":"text","label":"If YES, - Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number as allotted by insurance company","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Enter total sum insured 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":true,"pdf_field":""},{"help":"Use mm yy format","type":"date","label":"Date","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":true,"pdf_field":""},{"help":"Enter full name of insurance company","type":"text","label":"If Yes company name","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","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Tick the right option; if Other, specify","type":"choice","label":"Relationship of Primary Insured","options":["Self","Spouse","Child","Father","Mother","Other"],"required":true,"pdf_field":""},{"help":"Tick the right option; if Other, specify","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":true,"pdf_field":""},{"help":"Enter full postal address including 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":"text","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":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D - Details of Hospitalization","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of the Hospital where admitted","options":[],"required":true,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Room Category Occupied","options":["Day care","Single occupancy","Twin sharing","3 or more"],"required":true,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Hospitalization due to","options":["Illness","Injury","Maternity"],"required":true,"pdf_field":""},{"help":"Use dd mm yyyy format","type":"date","label":"Date of Injury / Disease first detected / Date of Delivery","options":[],"required":true,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh mm format","type":"text","label":"Time of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Use hh mm format","type":"text","label":"Time of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Tick the right option","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 system of medicine followed in treatment","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 in rupees","type":"amount","label":"Pre Hospitalization Expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post Hospitalization Expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health Check Up cost","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees and code if applicable","type":"amount","label":"Others (Code)","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount in rupees","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre Hospitalization Period","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post Hospitalization Period","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide details on annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Enter amounts for various lump sum benefits","type":"amount","label":"Detail of Lump Sum cash benefit claimed","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":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name and branch in full","type":"text","label":"Bank Name/ Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter name of beneficiary for payment","type":"text","label":"Payable details: Cheque/ DD/NEFT* Payable to","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Declaration by the Insured","fields":[{"help":"Enter date in dd:mm:yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Primary Insured Person / Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Claim Form - Part B (To be filled by the Hospital)","fields":[{"help":"Enter hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Hospital ID","options":[],"required":false,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Type of Hospital","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Registration No with State Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"IP Registration Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use DD MM YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Time of Admission","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Time of Discharge","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day-care","Maternity"],"required":true,"pdf_field":""},{"help":"","type":"date","label":"If Maternity Date of delivery","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Gravida Status","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Status at the time of Discharge","options":["Discharge to Home","Discharge to another Hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Enter total claimed amount","type":"amount","label":"Total Claimed Amount","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Ailment Diagnosed (Primary)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"ICD 10 Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Primary Diagnosis Codes Description","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Additional Diagnosis Codes Description","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Co-morbidities Codes Description","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Details of Procedure/s done","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"ICD 10 PCS Procedure 1 Code & Description","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Procedure 2 Code & Description","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Procedure 3 Code & Description","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Pre authorization Obtained","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Hospitalization due to Injury","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If Yes Give cause","options":["Self-Inflicted","Road Traffic Accident","Substance Abuse","Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to police","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Medico Legal","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"FIR No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If not reported to police, give reasons","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If injury due to Substance Abuse/ Alcohol consumption test conducted to establish this? If YES please attach Report","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Fill only if hospital is non-network","type":"text","label":"Details in case of Non network Hospital","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address of the Hospital","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":"text","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Registration no with state code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"No of Inpatient Beds","options":[],"required":false,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"Declaration by the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Basic Information and Accident Details","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Insured Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Insured Person Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Claimant Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"DOB","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Claim No","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Contact No Residence","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Time of Accident","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place & Location","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Description of accident/Incidence","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Details of injuries sustained","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Specify injured parts of the body","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Please specify nature of Disability","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage","type":"number","label":"Please mention Disability percentage in case of Permanent partial disablement, certified by Doctor","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Witnesses Name","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section for Claim Type Selection","fields":[{"help":"Tick all applicable claim types","type":"checkbox","label":"Tick Against the Section Claimed for","options":["Death","PTD","PPD","TTD","Child Education Support","Performance of Funeral Ceremony","Transportation of Mortal Remains","Modification of Vehicle / Residence","Accidental Medical Expenses","Family Transportation Benefit","Accidental Hospital Daily Cash","Outstanding Bills Protection","Life Support Benefit","Ambulance Hiring Charges","Loan Protector","Legal Bail Expenses","Broken Bone","Double Indemnity","Evacuation Expenses"],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Treatment Details","fields":[{"help":"","type":"text","label":"Casualty Doctor Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Family Doctor Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Hospital Details Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Confinement Inpatient treatment From","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Outpatient treatment From","options":[],"required":false,"pdf_field":""},{"help":"Actual days fully confined to bed on medical advice","type":"date","label":"Total Confinement From","options":[],"required":false,"pdf_field":""},{"help":"Attach separate sheet for additional bills/receipt details","type":"table","label":"Details of medical expenses Date, Receipt No, Particulars, Amount","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Policy and Claims History","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Have you made any Claims in Past?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If YES, Please give details including nature of Accident, Insurance details & Claim amount","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you insured under any other Policy?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If YES, Please give full particulars Name of Company, Policy No, Policy Period, Policy Issuing Office","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration by the Insured","fields":[{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Sign/ Thumb Impression of the Insured/ Insured Person","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Attending Physician Statement","fields":[{"help":"","type":"text","label":"Name & Age of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nature of the Accident","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Details of the Injuries sustained","options":[],"required":true,"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":true,"pdf_field":""},{"help":"If No, provide details","type":"yes-no","label":"Are the injuries solely due to the accident?","options":["Yes","No"],"required":true,"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":true,"pdf_field":""},{"help":"","type":"date","label":"Was the claimant hospitalized? If so for what period? From - To","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"What treatment was given and operations performed? Give all dates of treatment: Clinic/Hospital: From - To, Home: From - To","options":[],"required":false,"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":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you his family doctor?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Please give the details, If you have treated him for any previous illness or injury?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Have other Doctors been in Attendance or Consultation? If Yes, Please give the details","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Has this accident been reported to the Police Authorities? If Yes, then please provide Case No and Police Station","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is this claimant Totally Disabled from each and every occupation?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"date","label":"How long was or will the claimant be totally disabled from current occupation? From - To","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"How long was or will the claimant be partially disabled from current occupation? From - To","options":[],"required":false,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Estimated date of return to Work","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"What is the Prognosis?","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Doctor’s Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Tel No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Registration No","options":[],"required":false,"pdf_field":""},{"help":"Doctor to sign and seal","type":"signature","label":"Signature and Seal of the Doctor / Hospital","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"Group Personal Accident Policy claims including death, disability, hospitalization, and other benefits","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","Original Pre-Authorisation Request Form","Copy of Pre-Authorisation Approval Letter","Copy of Photo Id Card of Patient verified by the Hospital","MLC report & Police FIR","Original Death Summary from Hospital where applicable","FIR from police authorities wherever necessary","Death Certificate from the Municipal Authorities","Post Mortem Report, if conducted","Documentary proof of accidental death","Legal Heir Certificate & Succession Certificate","Policy Copy and Annexure","Inquest / Panchnama Report","Photographs of the insured","Coroner’s Report","Letter from HR stating the attendance closure to the incident","Medical Certificate from the attending Medical Practitioner for the injury indicating the extent of disability","Medical fitness certificate from the Treating consultant indicating duration of rest medically advised","Leave certificate from HR (for salaried people)","Salary certificate / income proof","Bills and receipts towards medical expenses","Copy of the test reports","X Ray plates reflecting broken bones","Bills and receipts towards vehicle or residence modifications","Bills and receipts towards travel expenses of family member/s","Proof of outstanding Bills","Bills and receipt towards cost of ambulance services","Doctor’s prescription advising the use of support devices","Loan documents from financial institution/s","Notice & Receipts of the bail expenses incurred","Proof of travel through Public Carrier and subsequent accident","Certificate from licensed physician about the diagnosis","Bills and receipts towards evacuation expenses"],"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 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 hospitals or medical practitioners.","Included all bills/receipts for this claim and will not make supplementary claims except pre/post-hospitalization claims if any.","Consent to Liberty General Insurance Limited to process/share personal information with group companies or service providers for insurance and related products.","Hospital declares that information furnished is true and correct to the best of their knowledge and belief; false statements will forfeit claim rights.","Claimant agrees to provide additional information if required and warrants truth of statements; false or fraudulent statements will void policy and claims.","Consent to Liberty General Insurance Limited to process/share personal information with group companies or service providers for insurance and related products."],"dropped_labels":17},"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/2275-liberty-group-personal-accident-policy-claim-form"}