{"id":667,"title":"Liberty Inland Travel Insurance For IRCT Customers Claim Form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Inland%20Travel%20Insurance%20for%20IRCTC%20Customers%20-%20Claim%20Form.pdf","sha256":"ac40d3939331f1f0d1a35b76dda42c332dc67a3c47f9a74c249bdf1653193a53","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by policyholders or claimants to file a claim under the Liberty Inland Travel Insurance for IRCTC customers. It collects details about the policy, claimant, and the nature of the claim to process insurance benefits.","notes":["Use additional sheets if required.","Refer to Annexure A for detailed documents required for each claim type.","Original bills and receipts must be submitted.","NEFT mandate and cancelled cheque with payee name are mandatory for claim payment.","Photo ID and address proof of policyholder and patient are required.","Claims above 1 lac require C-KYC form.","Policy wording should be read for detailed document requirements.","The form must be filled correctly and completely to avoid delays."],"title":"Liberty Inland Travel Insurance For IRCT Customers Claim Form","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":"Claimant and Policy Details","fields":[{"help":"","type":"text","label":"Master Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Holder Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claimant’s Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Certificate No.","options":[],"required":null,"pdf_field":""},{"help":"Passenger Name Record number from train booking","type":"text","label":"PNR No.","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Claimant’s Address:","options":[],"required":null,"pdf_field":""},{"help":"Mobile contact number","type":"phone","label":"Phone No. (Mobile):","options":[],"required":null,"pdf_field":""},{"help":"Residential phone number (optional)","type":"phone","label":"Phone No. (Res):","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Date format DDMMYYYY","type":"date","label":"Policy start date:","options":[],"required":null,"pdf_field":""},{"help":"Date format DDMMYYYY","type":"date","label":"Policy end date:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claim Details - Benefits to Claim","fields":[{"help":"For each section, indicate Yes or No and Claimed Amount if applicable. Sections: 1. Accidental Death, 2. Permanent Total Disablement, 3. Permanent Partial Disablement, 4. Emergency Accidental Hospitalization, 5. Transportation of Mortal Remains, 6. Train Delay, 7. Household Theft/Robbery (Contents)","type":"table","label":"Please tick the applicable benefit You want to claim for ?","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Full details of hospital or clinic where treatment was received","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic:","options":[],"required":null,"pdf_field":""},{"help":"Name and qualifications of the doctor who treated the patient","type":"text","label":"Treating Doctor's Name & Qualifications:","options":[],"required":null,"pdf_field":""},{"help":"Office phone number of the doctor","type":"phone","label":"Treating Doctor's Telephone Number: (O)","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number of the doctor","type":"phone","label":"(M)","options":[],"required":false,"pdf_field":""},{"help":"Hospital room or bed number","type":"text","label":"Room / Ward / Bed Number:","options":[],"required":false,"pdf_field":""},{"help":"Start date of treatment (DDMMYYYY)","type":"date","label":"Dates of treatment: From:","options":[],"required":null,"pdf_field":""},{"help":"End date of treatment (DDMMYYYY)","type":"date","label":"To:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Details and Doctor's Report","fields":[{"help":"Date symptoms started (DDMMYYYY)","type":"date","label":"Date of onset of symptoms:","options":[],"required":null,"pdf_field":""},{"help":"Date doctor was contacted (DDMMYYYY)","type":"date","label":"Date doctor contacted:","options":[],"required":null,"pdf_field":""},{"help":"Time of contact (HHMM)","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Date of accident (DDMMYYYY)","type":"date","label":"Date of Accident:","options":[],"required":null,"pdf_field":""},{"help":"Describe diagnosis and treatment given","type":"text","label":"State diagnosis and nature of treatment provided:","options":[],"required":null,"pdf_field":""},{"help":"Mention other diseases affecting condition, if any","type":"text","label":"Describe any other disease or infirmity affecting present condition:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the ailment due to Pregnancy:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the ailment aggravated due to any pre-existing condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of pre-existing condition if applicable","type":"text","label":"If yes, please give details:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Can the patient be evacuated to another location for Treatment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Doctor to sign and date the report","type":"signature","label":"Medical Doctor's Signature and Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"attending doctor"},{"title":"Disability Related Details","fields":[{"help":"Specify type of disability","type":"text","label":"Nature of Disability (Permanent/Partial):","options":["Permanent","Partial"],"required":null,"pdf_field":""},{"help":"Disability percentage as per medical assessment","type":"number","label":"Percentage of Disability:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Disability Certificate Issued:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"X- ray taken:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of diagnosis and treatment","type":"text","label":"Diagnosis and Treatment given:","options":[],"required":null,"pdf_field":""},{"help":"Doctor to sign","type":"signature","label":"Attending Doctor’s Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"attending doctor"},{"title":"Train Delay Details","fields":[{"help":"Attach official IRCTC confirmation letter","type":"attachment","label":"Confirmation letter from IRCTC stating the Reason for Train Delay with duration of delay:","options":[],"required":null,"pdf_field":""},{"help":"Name, relationship, and contact details if different from insured","type":"text","label":"Person Affected and Relationship with the Insured: (If not the Insured, please also provide address and contact details)","options":[],"required":null,"pdf_field":""},{"help":"Start date of original travel (DDMMYYYY)","type":"date","label":"Original Travel Dates: From:","options":[],"required":null,"pdf_field":""},{"help":"End date of original travel (DDMMYYYY)","type":"date","label":"To:","options":[],"required":null,"pdf_field":""},{"help":"Date of train delay (DDMMYYYY)","type":"date","label":"Train delayed on:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declarations and Signature","fields":[{"help":"Place where form is signed","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing (DDMMYYYY)","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 Liberty Inland Travel Insurance for IRCTC Customers including accidental death, disablement, hospitalization, train delay, transportation of mortal remains, and household theft/robbery","attachments":["Annexure A- Claim Documents Checklist as per claim type including hospital bills, discharge summary, doctor reports, railway authority reports, death certificate, FIR, disability certificate, NEFT mandate and cancelled cheque, photo ID and address proof, C-KYC form for claims above 1 lac, and other documents as applicable"],"declarations":["The information given in this claim form is true, correct and complete.","All interested parties in the property are disclosed and no duplicate claims have been made.","No material information relevant to the claim has been withheld.","False or fraudulent statements will void the policy and forfeit benefits.","Receipt of this form does not guarantee claim acceptance; further information may be required.","Authorization is given to ISM and Liberty General Insurance to obtain and share information for claim investigation and recovery.","Consent is given to Liberty General Insurance to process and share personal data with group companies or service providers."],"dropped_labels":0},"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/667-liberty-inland-travel-insurance-for-irct-customers-claim-form"}