{"id":699,"title":"Public Liability Insurance (Non-Industrial Risk) Policy – Claim Form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Public%20Liability%20Insurance%20(Non-Industrial%20Risk)%20Policy%20-%20Claim%20Form.pdf","sha256":"7941190d2216f1bd96605511960408d3fefbf6d9736f006c99b908aa8f29f80c","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or entity to file a claim under the Public Liability Insurance (Non-Industrial Risk) Policy for accidents causing injury or property damage.","notes":[],"title":"Public Liability Insurance (Non-Industrial Risk) Policy – Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the Insured","fields":[{"help":"","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Include country and area code if applicable","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide your insurance policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"List other insurers and policy numbers if applicable","type":"text","label":"Do you have any other insurance policies covering in respect to the same incident? If yes, give details of insurer, policy no., etc.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of accident","fields":[{"help":"Provide date and time when the accident happened","type":"date","label":"Date and Time of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Specify the location of the accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Explain the accident details including machinery type if involved","type":"text","label":"Describe fully how it had occurred? If from machinery, state type and how driven (i.e. steam, gas, electrical, etc.) and what work was being performed","options":[],"required":null,"pdf_field":""},{"help":"Explain what you did immediately after learning about the accident","type":"text","label":"Describe in detail your immediate actions taken upon receipt of the incident?","options":[],"required":null,"pdf_field":""},{"help":"Provide contractor details and attach contract copy","type":"text","label":"State name and contractor involved in the incident and attach a copy of the contract agreement","options":[],"required":null,"pdf_field":""},{"help":"Indicate if police report was filed and location","type":"text","label":"Was Police Report made? If yes, where?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of consequences of the accident – The Injured Person","fields":[{"help":"Provide detailed information about injured persons and circumstances","type":"text","label":"Has any person sustained any injuries in the accident? If so, (i) Give name/s, address/es and occupation/s of such person/s. (ii) State where such person was at the time of accident. (iii) Have the injured persons been removed to hospital or medically attended? If so, give particulars. (iv) Was the injured person in your direct employment? If no, please provide details of his employer. (v) What is the nature of his work? (vi) Was he guilty of any insobriety, misconduct or disobedience to instructions or rules? (vii) Nature and region of injury?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of consequences of the accident – Damage to Property of Others","fields":[{"help":"Describe damaged property or livestock and owner details","type":"text","label":"Has the accident caused damage to property or livestock? If so, give name/s and address/es of the owner/s of the property and/or livestock and full description of the property and state the nature of and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of claims made against you and attach documents if available","type":"text","label":"Has any claim been made upon you by any person? If so, state by whom and give full particulars (if claim has been made in writing, attach a copy of the notification received and of the bill, if submitted).","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated claim amounts for injuries, property damage, and claims made","type":"amount","label":"Estimated amount of claim separately under (a), (b) and (c)","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with their contact details","type":"text","label":"Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide authority details and attach report copy","type":"text","label":"Has the accident been reported to any authority? If so, state to whom and attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"help":"Describe any actions taken by authorities","type":"text","label":"What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies covering this risk","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Sign the form","type":"signature","label":"Insured's Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability Insurance (Non-Industrial Risk) Policy claims","attachments":["Copy of the contract agreement (if contractor involved)","Copy of police report (if made)","Copy of claim notification and bill (if claim made in writing)","Copy of report submitted to authority (if accident reported)"],"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 form or policy endorsement.","No similar claim has been made or lodged with any other insurance company except as disclosed.","False or fraudulent statements or concealment of material information will render the policy null and void and claims forfeited.","Receipt of this claim form or supporting documents does not constitute admission of liability by the company, which may require further information or reject the claim."],"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/699-public-liability-insurance-non-industrial-risk-policy-claim-form"}