{"id":691,"title":"CLAIM FORM FOR MONEY IN SAFE INSURANCE POLICY","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/MONEY%20INSURANCE%20POLICY%20-%20Claim%20Form%20money%20in%20Transit.pdf","sha256":"5bf2579e6996b01dadc41c632264439374ceefc02dd18ccb3a97238eb73dd3f5","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons to notify and claim for physical loss or damage of money kept in safe under the Money in Safe Insurance Policy.","notes":["The issue of this form is not an admission of liability.","Submit a copy of the police report as soon as possible."],"title":"CLAIM FORM FOR MONEY IN SAFE INSURANCE POLICY","submit":{"to":"Liberty General Insurance Limited","how":"","address":"Unit 1501 & 1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai - 400013"},"purpose":"claim","sections":[{"title":"Policy and Incident Details","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or damage occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"If assigned, enter claim number","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Insured","fields":[{"help":"Full name of the insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address to receive communication","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Primary contact number","type":"phone","label":"Contact Number (i)","options":[],"required":null,"pdf_field":""},{"help":"Alternate contact number (optional)","type":"phone","label":"Contact Number (ii)","options":[],"required":false,"pdf_field":""},{"help":"Additional contact number (optional)","type":"phone","label":"Contact Number (iii)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"Type of business or occupancy of premises","type":"text","label":"Business Occupancy","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss occurred","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Time when the loss occurred","type":"text","label":"Time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss or damage in detail","type":"text","label":"Description of Loss or Damage","options":[],"required":null,"pdf_field":""},{"help":"Date/time and person who discovered the loss","type":"text","label":"When was the loss discovered and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Monetary value of the loss","type":"amount","label":"Amount of loss","options":[],"required":null,"pdf_field":""},{"help":"Specify the policy schedule item applicable","type":"text","label":"Under what item of the policy schedule does this loss fall to be dealt","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Cash Conveyance Details","fields":[{"help":"Date and destination of cash conveyance","type":"text","label":"When send where was the cash being conveyed","options":[],"required":null,"pdf_field":""},{"help":"Person or entity conveying the cash","type":"text","label":"By whom?","options":[],"required":null,"pdf_field":""},{"help":"Person responsible for cash during loss","type":"text","label":"Who was responsible for the cash at the time of loss?","options":[],"required":null,"pdf_field":""},{"help":"Employment details and any fidelity insurance","type":"text","label":"In whose employment were the above parties and is there any fidelity guarantee insurance covering them","options":[],"required":null,"pdf_field":""},{"help":"Details of last receipt given for the cash","type":"text","label":"To whom and by whom was a receipt last given in respect of the cash lost?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Police Notification and Investigation","fields":[{"help":"Date and police station notified","type":"text","label":"When were the police notified and at what station?","options":[],"required":null,"pdf_field":""},{"help":"Investigation outcome and cash recovery details","type":"text","label":"What is the result of their investigation and has any cash been recovered?(Please submit as soon as possible copy of the police report)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Previous Loss and Other Insurance","fields":[{"help":"Indicate if similar loss was sustained previously","type":"yes-no","label":"Have you ever before sustained loss of this nature","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if other insurance covers this loss","type":"yes-no","label":"Are you insured against the present loss under any other policy","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing the declaration","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Money in Safe Insurance Policy","attachments":["Copy of the police report"],"declarations":["The statements and 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 similar claim has been made to any other insurer.","No material information relevant to the claim has been withheld or undisclosed.","If any false or fraudulent information is given or material information withheld, the policy shall be void and no claim rights will exist.","Receipt of this claim form or documents does not mean acceptance of the claim; the company may require further information or reject the claim."],"dropped_labels":3},"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/691-claim-form-for-money-in-safe-insurance-policy"}