{"id":679,"title":"CLAIM FORM FOR STANDARD FIRE & SPECIAL PERILS POLICY","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Standard%20fire%20and%20special%20perils%20-%20Claim%20Form.pdf","sha256":"fe9e396bb0a1673041b27349cb8913a61eeb7ac06dc47ad082020b6d8aeefde9","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured policyholder to notify and claim for physical loss or damage under the Standard Fire & Special Perils insurance policy.","notes":["The issue of this form is not to be taken as an admission of liability.","All claims must be based on the actual value of goods at the time of fire, excluding any profit.","Attach copies of other insurance policies if applicable."],"title":"CLAIM FORM FOR STANDARD FIRE & SPECIAL PERILS POLICY","submit":{"to":"Liberty General Insurance Limited","how":"","address":"10th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai - 400 013"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""},{"help":"Provide details if claimant is not sole owner","type":"text","label":"Is the claimant the sole owner of property damaged? If not state full particulars of any other interest","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Other Insurance","fields":[{"help":"If insured with other companies, attach copies of such policies","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No. (s).","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured Rs.","options":[],"required":null,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Loss","fields":[{"help":"Provide exact time and date of incident","type":"date","label":"Time & Date of Fire / Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of fire or loss","type":"text","label":"Cause of Fire / Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the affected insured items","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"State the use or occupation of the premises","type":"text","label":"Occupation of the premises at the time of Fire / Loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if reported to Fire Brigade and reasons if not","type":"yes-no","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if reported to Police and reasons if not","type":"yes-no","label":"Has the Fire / Loss been reported to Police? (If not, give reasons)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe actions taken to minimize loss","type":"text","label":"What steps were taken immediately to reduce the loss","options":[],"required":null,"pdf_field":""},{"help":"Provide location for inspection of loss","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe extent of loss in detail","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Additional Information","fields":[{"help":"Provide any other relevant details","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Loss Statement","fields":[{"help":"Fill columns: Item No. of Policy, Description of affected Property, Value at the time of Fire Rs., Deduction for Value of Salvage Rs., Net Amount Claimed Rs.","type":"table","label":"Details of claim for property destroyed or damaged","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Standard Fire & Special Perils Policy claims","attachments":["Copies of other insurance policies if insurance is effected with other companies"],"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 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 constitute admission of liability by the company."],"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/679-claim-form-for-standard-fire-and-special-perils-policy"}