{"id":677,"title":"CLAIM FORM FOR MACHINERY LOSS OF PROFIT Notification of Physical Loss or Damage","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Machinery%20Loss%20of%20Profits%20-%20Claim%20Form.pdf","sha256":"8512bfbb52929a64b2c88f954499bd250c29d01edee094ca2e2950bde0b3719e","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders to notify and claim for physical loss or damage under Machinery Loss of Profit insurance.","notes":[],"title":"CLAIM FORM FOR MACHINERY LOSS OF PROFIT Notification of Physical Loss or Damage","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":"Provide primary contact number","type":"phone","label":"Contact Number (i)","options":[],"required":true,"pdf_field":""},{"help":"Provide alternate contact number if any","type":"phone","label":"Contact Number (ii)","options":[],"required":false,"pdf_field":""},{"help":"Provide additional contact number if any","type":"phone","label":"Contact Number (iii)","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Policy and Loss Details","fields":[{"help":"Enter your policy or cover note number","type":"text","label":"Cover Note / Policy No","options":[],"required":true,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":true,"pdf_field":""},{"help":"Date when the loss or damage occurred","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"If already assigned, enter claim number","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Start date of insurance period","type":"date","label":"Period of Insurance From","options":[],"required":true,"pdf_field":""},{"help":"Date and time when loss occurred","type":"date","label":"Date and Time of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe the nature and cause of the loss or damage","type":"text","label":"Nature and Cause of Loss","options":[],"required":true,"pdf_field":""},{"help":"Provide details of any machinery breakdown insurance policy","type":"text","label":"Give details of Machinery Breakdown Insurance Policy covering the risk involved in the accident","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated financial loss amount","type":"amount","label":"Please give estimates of loss.","options":[],"required":true,"pdf_field":""},{"help":"Provide date and time when testing started if applicable","type":"date","label":"If yes then please specify date & time of commencement of testing.","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any previous claims on the same property during current policy period","type":"text","label":"Was any claim reported in the past on the same property during current policy period? If so, give details regarding Cause, Date of Accident, Claim Number, Policy issuing office, Amount of claim Paid/ outstanding","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declarations and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Machinery Loss of Profit insurance 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 form or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or undisclosed.","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 constitute acceptance of the claim; the company may require further information or reject the claim."],"dropped_labels":2},"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/677-claim-form-for-machinery-loss-of-profit-notification-of-physical-loss-or-damage"}