{"id":664,"title":"मोटर बीमा दावा प्रपत्र निजी कार/दो पहिया वाहन के लिए","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Claim%20Form%20-%20Private%20Car%20and%20Two%20Wheeler%20(Hindi).PDF","sha256":"86b327e7c274fa6b31cb972908cfe015f42c636874389d64758689172c4be169","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a motor insurance claim for private cars or two-wheelers. It is filled by the insured or claimant.","notes":["The claim form must be signed by the insured.","The damaged vehicle should be kept in a safe place to prevent further loss or theft.","Do not leave any part of the form unanswered; write 'N/A' if not applicable.","Delay in submitting the form due to unavailability of information is discouraged; additional reports can be sent later.","Use original documents for verification where specified.","For assistance, call toll-free number 1800 266 5844 or email care@libertyinsurance.in.","Gender options: पुरुष (Male), महिला (Female)."],"title":"मोटर बीमा दावा प्रपत्र निजी कार/दो पहिया वाहन के लिए","submit":{"to":"Liberty General Insurance Limited, care@libertyinsurance.in","how":"e-mail / post","address":"Email: care@libertyinsurance.in\nUnit No. 1501 & 1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai - 400013"},"purpose":"claim","sections":[{"title":"बीमाकृत / दावेदार का विवरण","fields":[{"help":"Enter the insurance policy period start and end dates","type":"date","label":"बीमा की अवधि d d / m m / y y y y से d d / mm/ x x x y","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number with country code","type":"phone","label":"मोबाइल +91","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"ईमेल ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"हानि / क्षति / दुर्घटना / चोरी का विवरण","fields":[{"help":"Date of accident/loss","type":"date","label":"दिनांक d d m m y y y y","options":[],"required":true,"pdf_field":""},{"help":"Time of accident/loss in hh:mm AM/PM format","type":"text","label":"समय h h : m m Α.Μ. / P.Μ.","options":[],"required":true,"pdf_field":""},{"help":"Contact numbers of witness","type":"phone","label":"संपर्क नंबर : दूरभाष एसटीडी कोड संख्या मोबाइल + 91","options":[],"required":false,"pdf_field":""},{"help":"Date of FIR/GDR/DDR","type":"date","label":"दिनांक ddm my yyy","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"वाहन का विवरण","fields":[{"help":"Date of vehicle registration","type":"date","label":"पंजीयन की तारीख d d m m y y y y","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"चालक का विवरण","fields":[{"help":"Driver's date of birth","type":"date","label":"जन्म तिथि d d / mm / yy","options":[],"required":false,"pdf_field":""},{"help":"Driver's mobile number with country code","type":"phone","label":"मोबाइल +91","options":[],"required":false,"pdf_field":""},{"help":"Driver's email address","type":"email","label":"ईमेल ID :","options":[],"required":false,"pdf_field":""},{"help":"License issue date","type":"date","label":"जारी किये जाने की तिथि ddmmy y y y","options":[],"required":false,"pdf_field":""},{"help":"License expiry date","type":"date","label":"वैधता दिनांक d d m m y y y y","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / claimant"},{"title":"घोषण पत्र","fields":[{"help":"Date of signing","type":"date","label":"तारीख : d d m m y y y y","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / claimant"}],"deadlines":[],"applies_to":"private car and two wheeler motor insurance claims","attachments":["दुर्घटना दावों के लिए:\n1. बीमे का प्रमाण - पॉलिसी/कवर नोट की प्रतिलिपि\n2. पंजीकरण पुस्तिका की प्रतिलिपि, कर की रसीद (कृपया सत्यापन के लिए मूल प्रति प्रस्तुत करें)\n3. दुर्घटना के समय वाहन चालक के मोटर ड्राइविंग लाइसेंस की प्रति (कृपया सत्यापन के लिए मूल प्रति प्रस्तुत करें)\n4. पुलिस पंचनामा/प्राथमिकी\n5. जहां वाहन की मरम्मत की जानी है, वहाँ के मरम्मतकर्ता से प्राप्त मरम्मत का मूल्यांकन\n6. मरम्मत कार्य के पूरा हो जाने के पश्चात प्राप्त हुए बिल/चालान और भुगतान की रसीदें\n7. उन्मोचन का वाउचर","चोरी के दावों के लिए:\n1. पॉलिसी के मूल दस्तावेज\n2. मूल पंजीकरण पुस्तिका/प्रमाण पत्र और कर भुगतान की रसीद\n3. चाबियों/सेवा पुस्तिका/वारंटी कार्ड/मूल क्रय इनवॉइस\n4. पुलिस पंचनामा/एफआईआर और अंतिम रिपोर्ट/पहुंच से बाहर रिपोर्ट\n5. आरटीओ को चोरी की सूचना और \"गैर-उपयोग\" की जानकारी देने के लिए प्रेषित पत्र की अभिस्वीकृति प्रतिलिपि\n6. बीमाकृत द्वारा हस्ताक्षरित फार्म 28, 29 और 30 तथा फाइनेंसर द्वारा हस्ताक्षरित फार्म 35\n7. प्रत्यासन के साथ खास मुख्तारनामा\n8. आपकी और फाइनेंसर की स्वीकृत दावा निपटान मूल्य के प्रति सहमति\n9. यदि दावे का निपटान आपके पक्ष में होना है तो फाइनेंसर से प्राप्त अनापत्ति प्रमाणपत्र\n10. क्षतिपूर्ति बंध-पत्र और उन्मोचन का वाउचर"],"declarations":["The insured confirms the truthfulness and fairness of all statements made in this form and any additional declarations related to the accident.","If any false or fraudulent statement is made or information is concealed, the company may reject the entire claim and cancel the policy.","The insured has attached the list of documents and understands that incomplete documentation may delay claim settlement.","The insured agrees to provide additional information or documents as requested by the company.","The insured authorizes the company to access relevant information for claim processing.","The insured voluntarily consents to the processing and sharing of personal data with group companies or service providers for insurance and related products."],"dropped_labels":60},"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/664-x"}