{"id":1996,"title":"PROPOSAL FORM FOR PUBLIC LIABILITY INSURANCE (NON-INDUSTRIAL RISKS)","purpose":"proposal","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/28-public-liability-insurance-(non-industrial-risks)8c0007ff45fd68ff8a0df0055fa6183b.pdf","sha256":"c55450b5aa709d3d438ef73df25d335544baabd6cf0e0c8ec44d960e466ff4e2","pages":11,"collected":"2026-10-20","instructions":{"about":"This form is a proposal for public liability insurance covering non-industrial risks. It is filled by the proposer seeking insurance coverage.","notes":["Answer all questions fully and correctly; mention 'not applicable' where needed","Insurance is a contract of utmost good faith; disclose all material facts","Liability of the company starts only after acceptance of proposal and payment of premium","Use additional sheets if space is insufficient","The AOA limit for extensions is within the overall limit specified in Risk Details section","Statutory warning on prohibition of rebates under Section 41 of Insurance Act 1938"],"title":"PROPOSAL FORM FOR PUBLIC LIABILITY INSURANCE (NON-INDUSTRIAL RISKS)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Client Information","fields":[{"help":"Write full name with spaces between parts","type":"text","label":"Proposer's name (please leave a space after each part of name)","options":[],"required":true,"pdf_field":""},{"help":"Write full mailing address with spaces between parts","type":"text","label":"Proposer's mailing address (please leave a space after each part of address)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"E-Mail Address","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Fax Number","options":[],"required":false,"pdf_field":""},{"help":"Describe relationship and position if applicable","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Details","fields":[{"help":"Write full address(es) with spaces; attach extra sheet if multiple","type":"text","label":"Address of Location(s) to be insured (please leave a space after each part of address and attach a separate sheet for multiple locations)","options":[],"required":true,"pdf_field":""},{"help":"Enter total number of locations","type":"number","label":"Number of locations to be insured","options":[],"required":true,"pdf_field":""},{"help":"Describe the trade or business activity","type":"text","label":"Proposer's trade or business","options":[],"required":true,"pdf_field":""},{"help":"Enter amount in million rupees","type":"number","label":"Paid-up capital of the firm (in ` Million)","options":[],"required":true,"pdf_field":""},{"help":"Enter number of years","type":"number","label":"How long have you been in business (in years)?","options":[],"required":true,"pdf_field":""},{"help":"Enter end date of policy period","type":"date","label":"Policy Period (DDMMYYYY) To","options":[],"required":true,"pdf_field":""},{"help":"Describe building construction type","type":"text","label":"Type of Construction","options":[],"required":true,"pdf_field":""},{"help":"Enter building age in years","type":"number","label":"Age of Building (in Years)","options":[],"required":true,"pdf_field":""},{"help":"Enter height in meters","type":"number","label":"Height of Building (in meters)","options":[],"required":true,"pdf_field":""},{"help":"Specify floor number or description","type":"text","label":"Which floor is being occupied by Proposer","options":[],"required":true,"pdf_field":""},{"help":"List other occupants with serial number and business nature","type":"table","label":"Please provide the details of other occupants of the building in the following format (attach separate sheet if required): Sr. No., Nature of business","options":[],"required":false,"pdf_field":""},{"help":"List lifts/escalators details","type":"table","label":"Please provide the following details of lifts, escalators etc (attach separate sheet if required): Sr. No., Make, Capacity, Year, Details","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are the premises or equipment or machinery in sound condition of operation and will they be maintained so? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe surrounding properties","type":"table","label":"Please provide details of the surrounding areas/property in the following format: Sr. No., Description of surrounding property, Year, Details","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Do you handle or use or store gases or hazardous or toxic or radioactive materials and/or equipment in the premises? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe maximum capacity","type":"text","label":"If yes, please give details of maximum capacity stored or used or handled at a time.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Required an increased premium or imposed special conditions? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If answer is yes to any of the above, please provide details in a separate sheet.","options":[],"required":false,"pdf_field":""},{"help":"Enter retroactive date if applicable","type":"date","label":"Please, state the retroactive date, i.e. the date from which policy was first incepted and continuously kept in force:","options":[],"required":false,"pdf_field":""},{"help":"Specify indemnity limits for AOA and AOY","type":"text","label":"Please indicate the limits of Indemnities during the period of Insurance in the following format: Limit of Indemnity Any One Accident (AOA) (`), Any One Year (AOY) (`)","options":[],"required":true,"pdf_field":""},{"help":"Select ratio","type":"choice","label":"Please specify the ratio of limit of indemnity for anyone accident (AOA) and Any One Year (AOY)","options":["1:1","1:2","1:3","1:4"],"required":true,"pdf_field":""},{"help":"Enter percentage of voluntary excess","type":"number","label":"Please indicate the voluntary excess as % of limit of indemnity per accident, which will entitle you to a discount in premium.","options":[],"required":false,"pdf_field":""},{"help":"Provide claims and premium history for last 3 years","type":"table","label":"Please give the claims and premium history for the preceding three years in the following format: Year, Total amount of claims paid (`), Total amount of claims outstanding (`), Total Premium, Disease/Bodily injury/Death, Loss or damage to property, Cost of defence actions","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are you presently insured under Public Liability policy for premises and/or transportation risk? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Security Measures: Does the premises have a boundary or fencing? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe security and safety arrangements","type":"text","label":"Please provide details of security/safety arrangements in the following format (in a separate sheet): Details","options":[],"required":false,"pdf_field":""},{"help":"Describe fire and explosion prevention systems","type":"text","label":"Please provide details of systems provided for prevention of fire, explosion etc. in the following format: Details","options":[],"required":false,"pdf_field":""},{"help":"Describe emergency plans","type":"text","label":"Details of emergency plans, if any.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Have you complied with all statutory rules and regulations pertaining to the premises and business activities? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If you are a Contractor for maintenance jobs, please answer the following questions: Terms of Contract, Number of persons employed, Are they qualified to carry out their jobs? Yes No, Are any cutting/ blasting/ mining operations involved? Yes No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Extensions and Additional Information","fields":[{"help":"Use additional sheets if space is insufficient","type":"text","label":"Any additional information relevant to the policy applied for","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Proposers Signature","options":[],"required":true,"pdf_field":""},{"help":"Print name of proposer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter designation if applicable","type":"text","label":"Designation","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Annexures (Industry Specific Details)","fields":[{"help":"Complete as applicable; use additional sheets if needed","type":"text","label":"Annexure I - For Hotels / Motels / Club Houses / Restaurants / Boarding and Lodging Houses / Guest Houses including Flight Kitchens: Provide details of restaurants, seating capacity, facilities, security measures, estimated annual turnover, maximum beds, average occupancy, club members, and select extensions required","options":["Act of God Perils Yes No","Industrial seepage, pollution, and contamination Yes No","Transportation Cover Yes No","Food and Beverages Yes No","Valuables of residents / bonafide members under Care, Control and Custody of Insured Yes No","Sports Facilities Yes No","Swimming Pool Yes No","Other facilities as specified Yes No"],"required":false,"pdf_field":""},{"help":"Complete as applicable","type":"text","label":"Annexure II - For Cinema Halls / Auditoriums / Theatres / Open Air Theatres / Public Halls: Provide maximum seating capacity, other facilities, estimated annual turnover, and select extensions required","options":["Act of God Perils Yes No","Industrial seepage, pollution, and contamination Yes No","Transportation Cover Yes No","Food and Beverages Yes No","Swimming Pool Yes No","Other facilities as specified Yes No"],"required":false,"pdf_field":""},{"help":"Complete as applicable","type":"text","label":"Annexure III - For Office / Residential Premises / Administration Premises / Medical Establishment / Research Institutions and Laboratories / Air Port Premises (Other than Aviation Liabilities): Provide details of facilities like canteens, sports etc, and select extensions required","options":["Act of God Perils Yes No","Industrial seepage, pollution, and contamination Yes No","Transportation Cover Yes No","Food and Beverages Yes No","Swimming Pool Yes No","Sports Facilities Yes No","Other facilities as specified Yes No"],"required":false,"pdf_field":""},{"help":"Complete as applicable","type":"text","label":"Annexure IV - For Schools / Educational Institutions / Public Libraries: Provide number of students, age distribution, hostel and canteen facilities, sports facilities, number of teachers, accident prevention measures, outings procedure, and select extensions required","options":["Act of God Perils Yes No","Industrial seepage, pollution, and contamination Yes No","Transportation Cover Yes No","Food and Beverages Yes No","Sports Facilities Yes No","Swimming Pool Yes No","Other facilities as specified Yes No"],"required":false,"pdf_field":""},{"help":"Complete as applicable","type":"text","label":"Annexure V - For Exhibitions / Fairs / Fetes / Circuses / Film Studios (Indoor and Outdoor) / Pandals / Tournaments / Zoos / Permanent Amusement Parks: Provide maximum seating capacity, area occupied, other facilities/games, estimated annual turnover, and select extensions required","options":["Act of God Perils Yes No","Industrial seepage, pollution, and contamination Yes No","Transportation Cover Yes No","Food and Beverages Yes No","Swimming Pool Yes No","Other facilities as specified Yes No"],"required":false,"pdf_field":""},{"help":"Complete as applicable","type":"text","label":"Annexure VI - For Warehouses / Godowns / Shops / Depots / Tank Farms: Provide types of items stored/sold, hazardous items details, statutory compliance, storage capacity, fire prevention measures, leakage possibility, estimated annual turnover, and select extensions required","options":["Act of God Perils Yes No","Industrial seepage, pollution, and contamination Yes No","Transportation Cover Yes No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":["Inform the insurer of any changes immediately, not later than 30 days"],"applies_to":"Public Liability Insurance for non-industrial activities","attachments":["Separate sheet for multiple locations","Separate sheet for other occupants of the building if required","Separate sheet for lifts, escalators details if required","Separate sheet for security/safety arrangements","Separate sheet for fire and explosion prevention systems","Additional sheets for extensions and annexure details if space is insufficient","Separate sheet for details if insurance declined or special conditions imposed"],"declarations":["The statements and particulars given are true, accurate and complete and form the basis of the contract","The company may share information with ICICI Group Companies or others as deemed necessary","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes","Premiums are paid from legally acquired sources of income","The company may call for documents to establish source of funds","The proposer undertakes to inform the company of any changes within 30 days","False or misleading information may lead to liability"],"dropped_labels":5},"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/1996-proposal-form-for-public-liability-insurance-non-industrial-risks"}