{"id":1617,"title":"FREE LOOK CANCELLATION REQUEST FORM","purpose":"service","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/downloads/free_look_cancellation_request_form.pdf","sha256":"52950b9383a18d749762027dcb9ff71e4141c4fbaefb393c9f620c62632aa1b6","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for policyholders of ICICI Lombard General Insurance Company Limited who wish to cancel their insurance policy within the free look period.","notes":["Free look option is not available in case of renewal.","Attach a blank cancelled cheque copy signed by the insured/nominee.","ICICI Lombard is not responsible for delays or non-credit of refund due to incomplete or incorrect information.","Use the policyholder's bank account number for refund; name particulars will not be used.","Original policy document and health card must be submitted."],"title":"FREE LOOK CANCELLATION REQUEST FORM","submit":{"to":"ICICI Lombard General Insurance Company Limited, Interface Building No.11, 401/ 402 4th Floor, New Link Road Malad (W), Mumbai - 400064.","how":"post","address":"ICICI Lombard General Insurance Company Limited, Interface Building No.11, 401/ 402 4th Floor, New Link Road Malad (W), Mumbai - 400064."},"purpose":"service","sections":[{"title":"POLICY & POLICY HOLDER'S DETAILS","fields":[{"help":"","type":"text","label":"Proposer's Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy start date as per your policy document","type":"date","label":"Policy Start Date:","options":[],"required":null,"pdf_field":""},{"help":"Date you received the policy document","type":"date","label":"Policy Receipt Date:","options":[],"required":null,"pdf_field":""},{"help":"Your mailing address","type":"text","label":"Correspondence 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":"6-digit postal code","type":"number","label":"Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Landline No. (with STD code):","options":[],"required":false,"pdf_field":""},{"help":"Your mobile phone number","type":"phone","label":"Mobile No.:","options":[],"required":null,"pdf_field":""},{"help":"Your email address","type":"email","label":"E mail address:","options":[],"required":false,"pdf_field":""},{"help":"Date of filling this form","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"REASON FOR FREE LOOK CANCELLATION","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Not satisfied with policy Terms & Conditions","options":["Not satisfied with policy Terms & Conditions"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Policy features are different from what was communicated","options":["Policy features are different from what was communicated"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Want to opt for different health plan of ICICI Lombard GIC","options":["Want to opt for different health plan of ICICI Lombard GIC"],"required":false,"pdf_field":""},{"help":"Specify other reason if any","type":"text","label":"Others (Please specify):","options":[],"required":false,"pdf_field":""},{"help":"Select one option","type":"choice","label":"Please tick on the channel through which you bought the policy): Agent/ Online/ Others","options":["Agent","Online","Others"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"DECLARATION","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Policy Holder","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"BANK DETAILS FOR NEFT","fields":[{"help":"Name as per bank records","type":"text","label":"Proposer's Name (as per bank records):","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for refund","type":"text","label":"Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name:","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the Bank:","options":[],"required":false,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"Branch IFSC Code:","options":[],"required":null,"pdf_field":""},{"help":"PAN card number","type":"text","label":"Permanent Account Number of Insured/ Nominee (PAN):","options":[],"required":false,"pdf_field":""},{"help":"Attach a signed blank cancelled cheque copy","type":"attachment","label":"(Please attach a blank cancelled cheque copy signed by the insured/nominee)","options":[],"required":true,"pdf_field":""},{"help":"Date of signing bank details","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Policy Holder","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"DOCUMENTS SUBMITTED","fields":[{"help":"Attach policy document","type":"checkbox","label":"Policy Document","options":["Policy Document"],"required":null,"pdf_field":""},{"help":"Attach health card","type":"checkbox","label":"Health Card","options":["Health Card"],"required":null,"pdf_field":""},{"help":"Attach cancelled cheque","type":"checkbox","label":"Cancelled Cheque for Refund","options":["Cancelled Cheque for Refund"],"required":null,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":["Free look cancellation can be availed within 15 days of receipt of the policy document"],"applies_to":"policies eligible for free look cancellation within 15 days of receipt of the policy document","attachments":["Policy Document","Health Card","Cancelled Cheque for Refund","blank cancelled cheque copy signed by the insured/nominee"],"declarations":["I am the holder of the insurance policy and voluntarily request cancellation within the free look period.","I understand payout will be as per policy terms and conditions.","I declare the details provided are correct and accurate.","I understand that health cover and benefits under this policy will cease after cancellation.","ICICI Lombard reserves the right to reject the free look request if conditions are not met."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"address","value":"ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025","label":"Registered Office Address","level":null,"hours":"normal business hours","applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":"t of policy with the term more than one year and the risk coverage for such policy years has not commenced.\n9 | P a g e ICICI Lombard General Insurance Company Limited EMI SURAKSHA IRDA Reg. No. 115 CIN: L67200MH2000PLC12940 UIN: IRDAN115RPMS0020V01202627\nMailing Address: Registered Office Address: Toll free no : 1800 2666\n13. Notices\nAny notice, direction or instruction given under th","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"address","value":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064.","label":"Office Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/sales-literature-prospectus-tripsecure-2.pdf","quote":"064. | ICICI Lombard General Insurance\nIRDA Reg. No. 115 | Company Limited\nMailing Address: | UIN: ICITIOP27058V022627\n601 / 602, 6th Floor, Interface Building No. 16, New | CIN: L67200MH2000PLC129408\nLink Road, Malad (West), Registered Office Address:\nICICI Lombard House, 414, P Balu | SALES LITERATURE / PROSPECTUS TRIPSECURE+\nMarg","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"email","value":"customersupport@icicilombard.com","label":"E-mail","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/sales-literature-prospectus-tripsecure-2.pdf","quote":"e, Prabhadevi, | Alternate No.: 86552 22666 (Chargeable)\nMumbai - 400 025. | Website | : www.iciclombard.com\nE-mail | : customersupport@icicilombard.com\nSections | Clause No | Cover Type | Cover Name | Payment Basis | Sum Insured | Deductible/ Special conditions\nTravel De","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800 2666","label":"Toll free number","level":null,"hours":"normal business hours","applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":"115 CIN: L67200MH2000PLC12940 UIN: IRDAN115RPMS0020V01202627\nMailing Address: Registered Office Address: Toll free no : 1800 2666\n13. Notices\nAny notice, direction or instruction given under this Policy shall be in writing and delivered by hand, pos","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Ground floor- Interface 11, Sixth floor- Interface 16 Office no 601 & 602, New linking Road, Malad (West), Mumbai – 400064","label":"Office Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/vibe-prospectus-(1).pdf","quote":"ombard.com Toll free number: 1800 2666 Email: customersupport@icicilombard.com ICICI Lombard General Insurance Co. Ltd. Ground floor- Interface 11, Sixth floor- Interface 16 Office no 601 & 602, New linking Road, Malad (West), Mumbai – 400064\nThere is an Interactive Voice Response (IVR) facility for senior citizens’ grievance redressal for easy and faster reso","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customersupport@icicilombard.com","label":"Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":"grievance the insured person may contact the Company through Website: www.icicilombard.com Toll free: 1800 2666 Email: customersupport@icicilombard.com ICICI Lombard General Insurance Co. Ltd. Ground floorInterface 11, Sixth floor- Interface 16 , Office no 601 & 602, New","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 2666","label":"Toll free","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":"115 CIN: L67200MH2000PLC12940 UIN: IRDAN115RPMS0020V01202627\nMailing Address: Registered Office Address: Toll free no : 1800 2666\n13. Notices\nAny notice, direction or instruction given under this Policy shall be in writing and delivered by hand, pos","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 4254 732","label":"IRDA Grievance Call Centre (IGCC)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":": Toll free no : 1800 2666 https://bimabharosa.irdai.gov.in/ or IRDA Grievance Call Centre(IGCC) at their toll free no. 1800 4254 732 / 155255\nMailing Address ICICI Lombard General Insurance Company Limited, ICICI Lombard House 414, Veer Savarkar Marg,","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.icicilombard.com/docs/defaultsource/policywordings-product-brochure/final-gro-mapping.pdf","label":"Branch details for grievance cell","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":"ach the grievance cell at any of the company's branches with the details of grievance. For branch details, please visit https://www.icicilombard.com/docs/defaultsource/policywordings-product-brochure/final-gro-mapping.pdf.\n17. lf lnsured person is not satisfied with the redressal of grievance ,insured person may contact the grievance redre","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.icicilombard.com/grievanceredressal.com","label":"Grievance redressal officer contact details","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/prospectus-emi-suraksha.pdf","quote":"ach the grievance cell at any of the company's branches with the details of grievance. For branch details, please visit https://www.icicilombard.com/docs/defaultsource/policywordings-product-brochure/final-gro-mapping.pdf.\n17. lf lnsured person is not satisfied with the redressal of grievan","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.icicilombard.com/docs/defaultsource/policy-wordings-product-brochure/final-gromapping.pdf","label":"Branch details for grievance cell","level":null,"hours":null,"applies_to":"all","source_url":"https://www.icicilombard.com/docs/default-source/default-document-library/vibe-prospectus-(1).pdf","quote":"cell at any of the company'sOur branches with the\ndetails | of | grievance. | For | branch | details, | please | visit\nhttps://www.icicilombard.com/docs/defaultsource/policy-wordings-product-brochure/final-gromapping.pdf.\nlf you are not satisfied with the redressal of grievance, You may contact the grievance officer at the details provide","fetched_at":"2026-10-20"}],"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/icici-lombard-general-insurance/1617-free-look-cancellation-request-form"}