{"id":696,"title":"Errors and Omissions Insurance - Claim form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Errors%20and%20Omissions%20Insurance%20-%20Claim%20Form.pdf","sha256":"a082aa234f51d4b91ab9b13a8d6b02d825294bba097e04dde4ff764e91248fcd","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to file a claim under their Errors and Omissions Insurance policy with Liberty General Insurance Limited.","notes":["The issue of this form is not to be taken as an admission of liability.","Attach all relevant supporting documents as indicated.","Declarations must be signed and dated by the insured."],"title":"Errors and Omissions Insurance - Claim form","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 the Insured","fields":[{"help":"","type":"text","label":"Name of Insured & Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy coverage period","type":"text","label":"Period of the Policy","options":[],"required":null,"pdf_field":""},{"help":"Specify the indemnity limits as per policy","type":"text","label":"Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Do you have any other insurance policies covering the same incident? If yes, give details of insurer, policy no., etc.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claimant","fields":[{"help":"Name of claimant and relationship to insured","type":"text","label":"Full Name of claimant ( Party claiming against you) and your business relationship","options":[],"required":null,"pdf_field":""},{"help":"Claimant's full address","type":"text","label":"Complete Address","options":[],"required":null,"pdf_field":""},{"help":"Claimant's contact number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Contract with the Claimant","fields":[{"help":"Describe service/work and attach contract copy","type":"text","label":"Details of service or work performed where the claim is made ( attach copy of contract)","options":[],"required":null,"pdf_field":""},{"help":"Provide date or period of work","type":"date","label":"Date or period when work was performed on which claim is made","options":[],"required":null,"pdf_field":""},{"help":"Name and designation of involved person","type":"text","label":"Name & Designation of person in your organization against whom claim is made","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Claim","fields":[{"help":"Date and time when incident occurred","type":"date","label":"Date & Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location of the incident","type":"text","label":"Place of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Narrate the incident details","type":"text","label":"Describe the events of the circumstance of the claim / allegation","options":[],"required":null,"pdf_field":""},{"help":"Date of first awareness","type":"date","label":"On which date you first become aware of the circumstances leading to a claim","options":[],"required":null,"pdf_field":""},{"help":"Date claim was first notified; attach correspondence","type":"date","label":"On what date the claim or the intimation of a claim first made to you? (Please provide copy of correspondence )","options":[],"required":null,"pdf_field":""},{"help":"Estimated claim amount with details","type":"amount","label":"What is the estimated amount of the claim & breakup","options":[],"required":null,"pdf_field":""},{"help":"Your opinion on claim amount and liability","type":"text","label":"What are your comments on the quantum of the claim and what is your estimate of your potential monetary liability, if any","options":[],"required":null,"pdf_field":""},{"help":"Indicate if legal proceedings started and attach documents","type":"yes-no","label":"Have the Legal proceedings commenced? Please attach copies of relevant documents such as but not limited to the summons /Claim or demand letters / along with replies made thereto / statement of defense made.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide defense counsel details and agreement copy","type":"text","label":"Whether any Defense Counsel appointed? If so, what is the lawyers name, firm, address, contact nos. and charge rates? (Please provide a copy of the agreement that you entered with the solicitor)","options":[],"required":null,"pdf_field":""},{"help":"Indicate if investigations/enquiries done and attach reports","type":"yes-no","label":"Whether any internal investigations / police / regulatory authorities’ enquiries conducted? - If yes, please provide copies of relevant reports of enquiries along with correspondence exchanged","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Additional relevant information","type":"text","label":"Any other details, which are important and you wish to share?","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim reported under other policy","type":"yes-no","label":"Has this Claim been reported under any other policy?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Sign the form","type":"signature","label":"Insured's Name and Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Errors and Omissions Insurance policies","attachments":["Copy of contract with claimant","Copy of correspondence for claim intimation","Copies of summons / Claim or demand letters / replies / statement of defense","Copy of agreement with defense counsel","Copies of reports of enquiries and correspondence"],"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.","False or fraudulent statements or concealment of material information will void the policy and forfeit claim rights.","Receipt of this form or documents does not constitute admission of claim liability; the company may require further information or reject the claim."],"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/696-errors-and-omissions-insurance-claim-form"}