{"id":681,"title":"CLAIM FORM FOR BURGLARY AND HOUSEBREAKING INSURANCE POLICY","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/BURGLARY%20AND%20HOUSEBREAKING%20INSURANCE%20POLICY%20-%20Claim%20Form.pdf","sha256":"a3408fb9264ef22161a97cd3f7b4c79dca39e17beb72aeb4598a9512c03345f0","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim for loss or damage due to burglary or housebreaking under their insurance policy.","notes":["The issue of this form is not to be taken as an Admission of Liability.","Attach copies of relevant insurance policies as required.","Fill all questions fully and accurately."],"title":"CLAIM FORM FOR BURGLARY AND HOUSEBREAKING INSURANCE POLICY","submit":{"to":"Liberty General Insurance Limited, Unit 1501 & 1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai - 400013","how":"post or as per company instructions","address":"Liberty General Insurance Limited, Unit 1501 & 1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai - 400013"},"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 a valid phone number","type":"phone","label":"Contact Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured the Sole Owner of the property? If yes please Provide","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe your interest in the property","type":"text","label":"Nature of Interest","options":[],"required":false,"pdf_field":""},{"help":"List persons with interest, their addresses and contact details","type":"text","label":"Person who have interest on Property along with address and contact details","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Loss or Damage","fields":[{"help":"Provide exact date and time of loss or damage","type":"date","label":"When did the loss or damage occur? (State date and time)","options":[],"required":true,"pdf_field":""},{"help":"Provide full address of the property","type":"text","label":"The address where the property (item) covered is situated.","options":[],"required":true,"pdf_field":""},{"help":"Describe how entry or exit is affected","type":"text","label":"Is entry or exit from premises affected?, if yes specify","options":[],"required":false,"pdf_field":""},{"help":"Describe the damage to premises","type":"text","label":"Is any portion of the premises damaged?, if yes specify","options":[],"required":false,"pdf_field":""},{"help":"State yes or no; if no, provide last occupancy date","type":"text","label":"Was the premise being occupied as on date of loss? If No specify the date of last occupancy","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated monetary value of loss or damage","type":"amount","label":"What is the estimated amount of loss or damage?","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance Details","fields":[{"help":"","type":"yes-no","label":"Is the property covered under Standard Fire and Special Perils Policy? if yes provide the below details for the policy, also attach the policy copy","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name on the other policy","type":"text","label":"Name of Insured","options":[],"required":false,"pdf_field":""},{"help":"Policy number of the other insurance","type":"text","label":"Policy No","options":[],"required":false,"pdf_field":""},{"help":"Period of the other insurance policy","type":"text","label":"Policy Period","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under the other policy","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the loss/damage covered under any other Insurance? If yes please provide the details, also attach policy copy","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Previous Losses and Additional Information","fields":[{"help":"Provide details of any losses in last 3 years","type":"text","label":"Details of Previous loss  (Losses during 3 preceding years)","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"Any additional information relevant to processing of claim :","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":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Burglary and Housebreaking Insurance Policy claims","attachments":["Policy copy if property is covered under Standard Fire and Special Perils Policy","Policy copy if loss/damage is covered under any other Insurance"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having interest in the property are disclosed as per proposal or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to claim processing has been withheld or undisclosed.","False or fraudulent statements or concealment of information will void the policy and forfeit claims.","Receipt of this claim form or documents does not constitute admission of liability by the company."],"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/681-claim-form-for-burglary-and-housebreaking-insurance-policy"}