{"id":716,"title":"Claim Form - Part A","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Health%20Prime%20Connect%20-%20Claim%20Form.pdf","sha256":"221d77cb5639a39ca87ba2732196ef2d0e54253c99d0987bfdd349b71aa73c9a","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for filing a health insurance claim by the insured person or policyholder to Liberty General Insurance. It collects details about the insured, hospitalization, and claim expenses.","notes":["To be filled in block letters.","The issue of this form is not to be taken as an admission of liability.","If ABHA ID is not available, visit https://abdm.gov.in/ to create one and inform the insurer.","If domiciliary hospitalization claim, provide details in annexure.","If non-network hospital, fill section E.","Original preauthorization request form must be included with Part B.","Use original bills and documents as listed in the checklist.","Signature of the insured must be taken after Part B is fully filled by the hospital."],"title":"Claim Form - Part A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Primary Insured","fields":[{"help":"","type":"text","label":"Policy No :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"SI. No/certificate No :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Company ID No :","options":[],"required":null,"pdf_field":""},{"help":"Enter surname, first name, middle name","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code :","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":"If ABHA ID is not available, create one at https://abdm.gov.in/ and inform us","type":"text","label":"ABHA Id :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insurance History","fields":[{"help":"","type":"choice","label":"Currently covered by any other Mediclaim / Health Insurance :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"dd mm yy","type":"date","label":"Date of commencement of first insurance without break :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Company Name :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No :","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured (Rs.) :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Have you been hospitalized in the last 4 year?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"dd mm yy","type":"date","label":"Date :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Diagnosis :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Previously covered by any other Mediclaim / Health Insurance :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, Company Name :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insured Person Hospitalized","fields":[{"help":"Enter surname, first name, middle name","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender :","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age : Year","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Months","options":[],"required":null,"pdf_field":""},{"help":"dd mm yy","type":"date","label":"Date of Brith","options":[],"required":null,"pdf_field":""},{"help":"If Other, please specify","type":"choice","label":"Relationship to Primary Insured :","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"If Other, please specify","type":"choice","label":"Occupation :","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address (if different from Above) :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code :","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No :","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID :","options":[],"required":false,"pdf_field":""},{"help":"If ABHA ID is not available, create one at https://abdm.gov.in/ and inform us","type":"text","label":"ABHA Id :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Detail of Hospitalization","fields":[{"help":"","type":"text","label":"Name of Hospital where Admitted :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Room Category Occupied :","options":["Day Care","Single Occupancy","Twin Sharing","3 Or more beds per room"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Hospitalization due to :","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"dd mm yy","type":"date","label":"Date of Injury / Date Disease First Detected / Date of Delivery :","options":[],"required":null,"pdf_field":""},{"help":"dd mm yy","type":"date","label":"Date of Admission :","options":[],"required":null,"pdf_field":""},{"help":"hh mm","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"dd mm yy","type":"date","label":"Date Of Discharge 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Post-hospitalization Period (days)","type":"table","label":"Details of The Treatment Expenses Claimed","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide details in annexure","type":"choice","label":"Claim for Domiciliary Hospitalization :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Columns: Hospital Daily Cash, Surgical Cash, Critical Illness Benefit, Hospitalization Expenses, Convalescence, Ambulance charges, Pre/Post Hospitalization Lump Sum Benefit, Other, Total","type":"table","label":"Details Of Lump sum / Cash Benefit Claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Primary Insured's Account","fields":[{"help":"","type":"text","label":"Pan :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Account Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Name and Branch :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cheque/ DD Payable details :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"ddmmyy","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place :","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Form - Part B (To be filled by Hospital)","fields":[{"help":"","type":"text","label":"Name of Hospital :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital ID :","options":[],"required":null,"pdf_field":""},{"help":"If non network fill section E","type":"choice","label":"Type of Hospital :","options":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"Enter surname, first name, middle name","type":"text","label":"Name of the treating doctor :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""},{"help":"Enter surname, first name, middle name","type":"text","label":"Name of the Patient :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IP Registration Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender :","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age : Year","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Months","options":[],"required":null,"pdf_field":""},{"help":"ddmmyy","type":"date","label":"Date of Brith :","options":[],"required":null,"pdf_field":""},{"help":"ddmmyy","type":"date","label":"Date of Admission :","options":[],"required":null,"pdf_field":""},{"help":"hh mm","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"ddmmyy","type":"date","label":"Date of Discharge :","options":[],"required":null,"pdf_field":""},{"help":"hh mm","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Type of Admission :","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Grade of status :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Status at time of discharge :","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Present ailment is a complication of PED?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, Specify Details :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Pre-authorization obtained :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Pre-authorization Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If authorization by network hospital not obtained, give reason :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Hospitalization due to Injury :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"If Yes, give cause","options":["Self-inflicted","Road Traffic Accident","Substance abuse/ alcohol consumption"],"required":false,"pdf_field":""},{"help":"If Yes, attach report","type":"choice","label":"If injury due to substance abuse/ alcohol consumption, Test Conducted to establish this :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If Medico Legal :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"FIR no :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If not reported to police give reason:","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details in Case of Non Network Hospital","fields":[{"help":"","type":"text","label":"Address of Hospital :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Number of Inpatient beds :","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"ddmmyy","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place :","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature and Seal of the hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance claims under Liberty General Insurance policies","attachments":["copy of policies","MLC Report & Police FIR (if applicable)","Claim Form Duly Signed","Operation Theater Notes","Copy of the claim Intimation","ECG","Doctor's Request For Investigation","Hospital Main Bill","Hospital Break-up Bill","Investigation Report (Including CT / MRI/ USG / HPE)","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Original Preauthorization request form (for Part B)","Copy of Pre-authorization Approval letter","Copy of photo ID card of patient verified by hospital","MLC report & Police FIR (if applicable)","Original death summary from hospital where applicable"],"declarations":["The information furnished in this claim form is true and correct to the best of the insured's knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent is given to the insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claims.","Consent is given to Liberty General Insurance Limited to process and share personal information with group companies or service providers for insurance and related products.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements by the hospital will forfeit their right to claim under this claim."],"dropped_labels":9},"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/716-claim-form-part-a"}