{"id":1619,"title":"PORTABILITY / MIGRATION 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/default-document-library/portability-and-migration-form.pdf","sha256":"51e4d2f4874b7dca78aacb353c325ac90082154f22934e5116a2bccba0f7a0b1","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for policyholders who want to port or migrate their health insurance policy to ICICI Lombard. The policyholder fills it to provide details of previous insurance and claims for portability or migration.","notes":["Fill only relevant sections as per requirement for portability or migration.","Attach additional sheets if required.","Use original documents for supporting proofs.","The company's decision is based on information and supporting documents provided.","Portability/Migration is subject to underwriting and company approval."],"title":"PORTABILITY / MIGRATION FORM","submit":{"to":"","how":"","address":"Mailing Address: Interface Building No. 16, 601-602, 6th Floor, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"service","sections":[{"title":"Details of Proposed Insurance","fields":[{"help":"","type":"number","label":"No. of members to be covered","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured opted for (`) :","options":[],"required":null,"pdf_field":""},{"help":"Explain why you want to port or migrate your policy","type":"text","label":"Reasons for Portability/Migration :","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Policy Holder","fields":[{"help":"Enter mobile number","type":"phone","label":"Mobile No. :","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID :","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address of the Policyholder:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender:","options":["M","F","T"],"required":null,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of the Policyholder :","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Portability / Migration Form - Part I","fields":[{"help":"Enter proposal form number if any","type":"text","label":"Proposal Form No:","options":[],"required":null,"pdf_field":""},{"help":"Provide cumulative bonus details","type":"text","label":"What was the cumulative bonus in previous policy:","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Whether cumulative bonus to be converted to an enhanced Sum Insured.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Portability/Migration Form - Part A (Only applicable for Migration)","fields":[{"help":"Fill details for each insured for up to 5 entries: Insured Name, Date of Birth, No of years covered, Pre-Existing diseases, Sum Insured, Additional Sum Insured / Cumulative Bonus, Date of joining (with first Insurer)","type":"table","label":"Sr.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of the Past Retail Health Insurance Policies / Details of the Past Group Health Insurance Policy of ICICI Lombard - Part B","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Have you or any person proposed to be insured under the Policy ever refused Insurance cover by an Insurance company or been accepted on special terms?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain refusal or special terms if applicable","type":"text","label":"If yes, please give full details.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you or any person proposed to be insured under the policy ever covered Maternity Benefit?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter policy duration if maternity benefit is covered","type":"text","label":"I) Policy Duration","options":[],"required":null,"pdf_field":""},{"help":"Enter maternity sum insured if applicable","type":"amount","label":"ii) Maternity Sum Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Past / Existing Health Insurance Policies","fields":[{"help":"Fill for up to 4 policies: Policy Start Date, Policy End Date, Name of the Policy, Add ons/Riders in the policy, Policy Number/ UHID","type":"table","label":"Sr. No.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Past Claims","fields":[{"help":"Fill for up to 4 claims: No of claims, Claim amount, Nature of claim","type":"table","label":"Sr. No.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Employee Details","fields":[{"help":"If applicable, enter employee name","type":"text","label":"Name of the Employee:","options":[],"required":null,"pdf_field":""},{"help":"If applicable, enter employee ID","type":"text","label":"Employee ID:","options":[],"required":null,"pdf_field":""},{"help":"If applicable, enter company name","type":"text","label":"Company:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number or UHID","type":"text","label":"Policy Number/ UHID","options":[],"required":null,"pdf_field":""},{"help":"Enter product name","type":"text","label":"Product Name :","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Part II - Declaration and Consent","fields":[{"help":"Enter date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the policyholder","options":[],"required":true,"pdf_field":""},{"help":"Tick if you agree","type":"checkbox","label":"I hereby agree to observe the additional waiting period.","options":[],"required":null,"pdf_field":""},{"help":"Specify waiting period if applicable","type":"text","label":"I am aware that the waiting period for the following disease(s)/treatment(s) is _____________ days/years more than the previous policy terms.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Whether the Pre-Existing Diseases exclusions / time bound exclusion have longer exclusion period than the existing policy:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name again for declaration","type":"text","label":"Name of the Policyholder :","options":[],"required":null,"pdf_field":""},{"help":"Enter date again for declaration","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter place again for declaration","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign again for declaration","type":"signature","label":"Signature of the policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":["Portability/Migration benefit allowed only for the completed years of continuous health insurance coverage.","Group health to Retail health migration allowed only when the insured migrates out of the Group covered under ICICI Lombard Group Health Policy and applied within 30 days of such migration.","The application of portability is provided at least 45 days prior to policy renewal date along with the required supporting documents.","Any pre-policy medical check is completed within 7 days of intimation.","Any additional information is provided within 7 days of such request."],"applies_to":"portability (from other insurers retail health insurance policy to ICICI Lombard retail health policy) or migration (from ICICI Lombard group health policy to ICICI Lombard retail health policy)","attachments":["Copy of last 3 years policy schedule issued by the previous insurer or renewal notice"],"declarations":["I hereby agree to observe the additional waiting period.","I am aware that the waiting period for certain diseases/treatments is longer than previous policy terms.","I declare that the statements and particulars given are true, accurate and complete and form the basis of the contract.","Acceptance of Portability/Migration is subject to underwriting and company norms.","ICICI Lombard must receive information from previous insurer in time to process the application.","If maternity benefit is ported, waiting period benefit applies as per previous coverage."],"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/1619-portability-migration-form"}