{"id":687,"title":"CLAIM FORM FOR FIDELITY GUARANTEE INSURANCE POLICY","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/FIDELITY%20GUARANTEE%20INSURANCE%20POLICY%20-%20Claim%20Form.pdf","sha256":"88501175458d4453913d9108984530cb390864f2a14ff57ed5a44a0011a9c999","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and claim for a loss under the Fidelity Guarantee Insurance Policy due to defalcation by an employee.","notes":["The issue of this form is not to be taken as an Admission of Liability.","Please answer all questions fully.","If space is insufficient, attach separate signed sheets with detailed particulars.","Attach certified statement of book entries related to the defalcation.","Declaration must be signed by the insured."],"title":"CLAIM FORM FOR FIDELITY GUARANTEE 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 / in person","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":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":""}],"filled_by":"insured"},{"title":"Details of Defaulting Employee and Loss","fields":[{"help":"","type":"text","label":"Defaulting Employee Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of Defaulting Employee","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Amount of loss sustained ( In Rs)","options":[],"required":null,"pdf_field":""},{"help":"Date when the defalcation occurred","type":"date","label":"Date of Defalcation","options":[],"required":null,"pdf_field":""},{"help":"Date when the defalcation was discovered","type":"date","label":"Date of discovery of defalcation","options":[],"required":null,"pdf_field":""},{"help":"Describe the method of defalcation in detail","type":"text","label":"How exactly was the defalcation committed? (If this space is not sufficient, please give full & detailed particulars on a separate signed sheet. Also please attach a certified statement containing all entries in your books of accounts relative to the declaration in their order of dates).","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Duties and Related Details","fields":[{"help":"Describe the employee's role and location","type":"text","label":"In what capacity was he engaged and where?","options":[],"required":null,"pdf_field":""},{"help":"Explain how money was handled by the employee","type":"text","label":"In what way did moneys reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"Specify the maximum amount held and duration","type":"amount","label":"What was the largest sum which he had in his hands at any one time and for how long?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was he allowed to pay out any amounts on your behalf?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name the person(s) authorizing payments","type":"text","label":"Who authorized these payments?","options":[],"required":null,"pdf_field":""},{"help":"Explain receipt issuance and checking process","type":"text","label":"Was he required to give printed receipts from a book with counterfoils? If so, how often were the counterfoils examined and checked, and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Describe bank deposit and verification procedures","type":"text","label":"Where moneys paid into the Bank by the defaulting employee? If so, how often were the Bank books examined and checked, and by whom?","options":[],"required":null,"pdf_field":""},{"help":"State any cash balance allowed with employee","type":"amount","label":"What balance, if any was allowed to be kept in his hand?","options":[],"required":null,"pdf_field":""},{"help":"Describe cash account reconciliation process","type":"text","label":"How often were his Cash Accounts balanced and how was their accuracy checked? Please explain fully.","options":[],"required":null,"pdf_field":""},{"help":"Frequency of independent account statements to customers","type":"text","label":"How often were accounts sent direct to Customers independently of the employee?","options":[],"required":null,"pdf_field":""},{"help":"Details on stock control and verification frequency","type":"text","label":"Did the employee have charge of stock? If so, how often was it checked?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Audit and Security Details","fields":[{"help":"Audit frequency and auditor details","type":"text","label":"How often were the Account Books at the place of the defaulting employees employment audited and by whom?","options":[],"required":null,"pdf_field":""},{"help":"List any assets held from the employee","type":"text","label":"Have you any moneys, estate, or effect of the employee in your possession? If so, give particulars with amounts.","options":[],"required":null,"pdf_field":""},{"help":"Describe any other securities held","type":"text","label":"Do you hold any other security from the Employee? If so, state its nature and amount.","options":[],"required":null,"pdf_field":""},{"help":"Details of family or property held by employee","type":"text","label":"Is the defaulter a member of a joint family, or does he hold any property furniture or other effects? If so, give details.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide names and addresses of relatives","type":"text","label":"Has the employee any near relatives? If so, give their names and address if known.","options":[],"required":null,"pdf_field":""},{"help":"Describe any disciplinary or legal action taken","type":"text","label":"Have you taken any action against the employee? If so, state of what nature.","options":[],"required":null,"pdf_field":""},{"help":"Police report details and actions taken","type":"text","label":"Has the loss been reported to the Police? If so, state at which Police Station and what action, if any, has been taken by them.","options":[],"required":null,"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","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Fidelity Guarantee Insurance Policy claims","attachments":["Certified statement containing all entries in your books of accounts relative to the declaration in their order of dates"],"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 not disclosed.","If any false or fraudulent information is given, the policy shall be void and claims forfeited.","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/687-claim-form-for-fidelity-guarantee-insurance-policy"}