{"id":675,"title":"CLAIM FORM FOR MACHINERY BREAKDOWN INSURANCE POLICY","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Machinery%20Breakdown%20-%20Claim%20Form.pdf","sha256":"3e19855be24e2a4fd44286a827180611e709af0f89332d93134a30cdc18ed9b5","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming physical loss or damage under a machinery breakdown insurance policy. It is filled by the insured person or policyholder.","notes":["The issue of this form is not an admission of liability.","Answer all questions fully.","The form must be signed and dated by the insured."],"title":"CLAIM FORM FOR MACHINERY BREAKDOWN INSURANCE POLICY","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss or Damage Details","fields":[{"help":"Provide exact date and time of the incident","type":"date","label":"When did the loss or damage occur? (State date and time)","options":[],"required":true,"pdf_field":""},{"help":"Location of the insured machinery","type":"text","label":"The address where the property (item) covered is situated.","options":[],"required":true,"pdf_field":""},{"help":"Brief description of the machine","type":"text","label":"Description of Machine","options":[],"required":true,"pdf_field":""},{"help":"Provide serial number, make, model and other specifications","type":"text","label":"Specification of Machine (Serial No, make, Model etc)","options":[],"required":true,"pdf_field":""},{"help":"Describe the extent of damage or loss","type":"text","label":"Extent of loss","options":[],"required":true,"pdf_field":""},{"help":"Explain cause and circumstances of damage","type":"text","label":"What was the cause of the damage and how did it occur?","options":[],"required":true,"pdf_field":""},{"help":"Provide detailed explanation of the damage event","type":"text","label":"How did the damage occur? (This question must be answered in detail)","options":[],"required":true,"pdf_field":""},{"help":"Location for physical inspection of damaged machinery","type":"text","label":"Address where the damaged items can be inspected","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated financial loss","type":"amount","label":"What is the estimated amount of loss or damage?","options":[],"required":true,"pdf_field":""},{"help":"Mention other insurance policies covering the item if any","type":"text","label":"Details of any other existing insurance","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant details","type":"text","label":"Any additional information relevant to processing of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Machinery Breakdown Insurance Policy claims","attachments":[],"declarations":["The statements/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 endorsement and no other claim has been made for the same loss.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and rights to claim.","Receipt of this claim form or documents does not constitute acceptance of the claim and the company may require further information or reject the claim."],"dropped_labels":1},"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/675-claim-form-for-machinery-breakdown-insurance-policy"}