{"id":672,"title":"CLAIM FORM FOR ELECTRONIC EQUIPMENT INSURANCE POLICY","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/ELECTRONIC%20EQUIPMENT%20INSURANCE%20POLICY%20-%20Claim%20Form.pdf","sha256":"ce140f6eb80f38112bdfb0ede93b3b15c13683331d8a81b84c5768073f6772da","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage to electronic equipment covered under the insurance policy.","notes":["The issue of this form is not an admission of liability by the insurer.","Major repairs require prior consent and approval of the company."],"title":"CLAIM FORM FOR ELECTRONIC EQUIPMENT INSURANCE POLICY","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the Insured and Loss","fields":[{"help":"Enter your policy or cover note number","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or damage occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"If already assigned, enter claim number","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured person or entity","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address to receive communication","type":"text","label":"Address for correspondance","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the insured","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Date and time when the loss occurred","type":"date","label":"Date and Time of Loss?","options":[],"required":null,"pdf_field":""},{"help":"Location of the insured equipment at time of loss","type":"text","label":"The address where the property (item) covered is situated.","options":[],"required":null,"pdf_field":""},{"help":"Describe the damaged electronic equipment fully","type":"text","label":"Full description of the equipment damaged","options":[],"required":null,"pdf_field":""},{"help":"Policy schedule item number for the equipment","type":"text","label":"Item Number in the policy schedule","options":[],"required":null,"pdf_field":""},{"help":"Declared value of the damaged item","type":"amount","label":"Value of the damaged equipment","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage to the equipment","type":"text","label":"Details of damage sustained","options":[],"required":null,"pdf_field":""},{"help":"Explain how the damage or loss happened","type":"text","label":"Cause of Breakdown or Loss","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any guarantee applicable","type":"text","label":"State whether item damaged was under any guarantee from supplier/ Manufacturer/ repairer. If so, state the nature of guarantee and guarantee period","options":[],"required":null,"pdf_field":""},{"help":"Mention any previous damage and repairs","type":"text","label":"Did the equipment in question suffer any earlier damage due to accident? If so, give particulars with details of repairs executed?","options":[],"required":null,"pdf_field":""},{"help":"Describe usage and location of equipment when damaged","type":"text","label":"In which section and for what purpose was the equipment being used at the time of loss?","options":[],"required":null,"pdf_field":""},{"help":"Provide repairer details if repairs started","type":"text","label":"Have the repairers commenced repairs? If so, give the name and address of the repairers","options":[],"required":null,"pdf_field":""},{"help":"Describe repairs and parts to be replaced","type":"text","label":"State nature of repairs and particulars of replacement of parts required","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated repair or replacement cost","type":"amount","label":"Estimate of the cost of repairs / replacement (Any major repairs are to be executed only with prior consent and approval of the company)","options":[],"required":null,"pdf_field":""},{"help":"Value of damaged items salvageable","type":"amount","label":"State salvage value on the damaged items","options":[],"required":null,"pdf_field":""},{"help":"Location for inspection of damaged equipment","type":"text","label":"Where can the damaged items be inspected","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other insurance covers this loss","type":"yes-no","label":"Are there any other insurance effected by you or any other person covering the loss sustained or any part thereof?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Any additional relevant information","type":"text","label":"Please give any other particulars relevant to the damage","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here to declare the information is true","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Electronic Equipment Insurance Policy claims","attachments":[],"declarations":["The statements and information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal or policy endorsements and no other claim for the same loss has been made to any other insurer.","No material information relevant to the claim has been withheld or concealed.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of this claim form or documents does not mean acceptance of the claim; the company may require further information or reject the claim."],"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/672-claim-form-for-electronic-equipment-insurance-policy"}