{"id":1999,"title":"PROPOSAL FORM FOR ICICI BHARAT LAGHU UDYAM SURAKSHA","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/20241007018-icici-bharat-laghu-udyam-suraksha-forms-8c0007ff45fd68ff8a0df0055fa61f2b.pdf","sha256":"2ee28e77a784c74bb0b17a9bab3c580f9bfcd3e077b71d1d71b3dfc4def77b3b","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used by enterprises with insurable assets between ₹5 Crore and ₹50 Crore to apply for fire and allied perils insurance coverage. It is filled by the proposer (policyholder).","notes":["Read the Prospectus/Key Features Document/Policy Wordings before filling the form.","The property is not covered until proposal is accepted and premium is paid.","Kutcha construction means walls/roofs of wooden planks, thatched leaves, grass, bamboo, plastic cloth, asphalt, canvas, tarpaulin etc.","Pucca construction means buildings other than Kutcha.","Use the exact labels as printed for each field.","Declaration section must be signed by proposer and witnessed.","If proposer is illiterate or signs in vernacular, a declaration by the person explaining the form is required.","No rebate of commission or premium is allowed as per Insurance Act 1938."],"title":"PROPOSAL FORM FOR ICICI BHARAT LAGHU UDYAM SURAKSHA","submit":{"to":"Mailing Address: 601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064.","how":"post","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"proposal","sections":[{"title":"A. DETAILS ABOUT PROPOSER AND POLICY PERIOD","fields":[{"help":"","type":"text","label":"Policy Issuing Office Address & Code","options":[],"required":null,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"Intermediary/Agent Name  & Code (if any)","options":[],"required":false,"pdf_field":""},{"help":"Full name of the proposer","type":"text","label":"Name of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Include area code","type":"phone","label":"Telephone  No. (Landline)","options":[],"required":false,"pdf_field":""},{"help":"Mobile contact number","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Name of contact person if proposer is not an individual","type":"text","label":"Contact person details, if not an individual - Name","options":[],"required":false,"pdf_field":""},{"help":"List all parties with insurable interest","type":"text","label":"Policy to be Issued in favour of (list out all the parties who have insurable interest) including the financial institutions","options":[],"required":true,"pdf_field":""},{"help":"Politically Exposed Persons status","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain relationship and position if PEP","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you wish to avail policy documents in physical form","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of nominee","type":"text","label":"Nominee Name","options":[],"required":false,"pdf_field":""},{"help":"Nominee's relationship to insured","type":"text","label":"Relationship with the Insured","options":[],"required":false,"pdf_field":""},{"help":"Nominee's mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Nominee's email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Nominee's address","type":"text","label":"Present & Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Name of authorized person if nominee is minor","type":"text","label":"Authorized person for Minor Nominee","options":[],"required":false,"pdf_field":""},{"help":"Bank details for refund or payments","type":"text","label":"Bank Details","options":[],"required":false,"pdf_field":""},{"help":"Select the type of proposer","type":"choice","label":"Type of Proposer","options":["Individual","Partnership firm","MSME/SME","Company","Govt.","Others"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"B. BUSINESS AND LOCATION OF BUSINESS","fields":[{"help":"Describe the business","type":"text","label":"Business of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Serial number for multiple locations","type":"number","label":"Sr. No.","options":[],"required":false,"pdf_field":""},{"help":"Full postal address of business location","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin code","options":[],"required":true,"pdf_field":""},{"help":"Type of occupancy at location","type":"text","label":"Occupancy","options":[],"required":true,"pdf_field":""},{"help":"Age of building or business at location","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"Floor details (e.g. GF, MF, Higher Floor)","type":"text","label":"Floor","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"C. DETAILS ABOUT BUSINESS COVERED AT THE INSURED LOCATION","fields":[{"help":"Tick all applicable property types","type":"checkbox","label":"The Insured property is (Please tick in the space below)","options":["Offices, shops, hotels etc.","Industrial / manufacturing risks","Storage outside Industrial / manufacturing risks","Tanks / gas holders outside industrial / manufacturing risks","Utilities located outside Industrial / manufacturing risks","Boundary wall","Basement storage","Others (please specify)"],"required":true,"pdf_field":""},{"help":"Value of goods stored if applicable","type":"amount","label":"If, yes value stored Sl: `","options":[],"required":false,"pdf_field":""},{"help":"List goods stored in warehouse","type":"text","label":"If used as warehouse / godown (not located in a manufacturing unit) please give the list of goods stored.","options":[],"required":false,"pdf_field":""},{"help":"List products manufactured","type":"text","label":"If used as an Industrial Manufacturing unit give products manufactured at the location proposed (detailed block plan showing various facilities to be enclosed wherever applicable)","options":[],"required":false,"pdf_field":""},{"help":"Select factory status","type":"choice","label":"If used as an Industrial Manufacturing unit, please state whether the factory is working or silent?","options":["Working","Silent"],"required":false,"pdf_field":""},{"help":"Tick all fire protection devices installed","type":"checkbox","label":"Fire Protection devices installed (Please Tick the correct answer in the box below)","options":["Portable Extinguishers","Small bore hose reels","Trailer Pumps/Fire engines","Hydrant System","Sprinkler System","Fixed Water Spray System","Foam System","Fire Alarm System","Gas Flooding System","Others, please specify"],"required":false,"pdf_field":""},{"help":"Is AMC active for fire protection devices?","type":"yes-no","label":"Indicate whether AMC (Annual Maintenance contract) for the Fire Protection Appliances is in force","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"D. SUM INSURED AND OTHER DETAILS OF INSURED PROPERTY","fields":[{"help":"Describe the block or building","type":"text","label":"Description of Block","options":[],"required":true,"pdf_field":""},{"help":"Reinstatement value","type":"amount","label":"Building including plinth, Basement, and additional structures (Sum Insured in ₹)","options":[],"required":true,"pdf_field":""},{"help":"Reinstatement value","type":"amount","label":"Furniture & Fixtures, Fittings and other equipment (Sum Insured in ₹)","options":[],"required":true,"pdf_field":""},{"help":"Number of floors in building","type":"number","label":"Number of Floors","options":[],"required":false,"pdf_field":""},{"help":"Select age category","type":"choice","label":"Age of the Building","options":["Less than 5 years","5-10 years","10-20 years","Above 20 years"],"required":false,"pdf_field":""},{"help":"Distance in km or meters","type":"text","label":"Distance between the risk to be covered and nearest Fire Brigade","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"E. STANDARD ADD ON","fields":[{"help":"Address of additional locations","type":"text","label":"Floater Cover (for stocks at various locations) - Location (Postal Address with Pin Code)","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for floater cover","type":"amount","label":"Sum Insured (in ₹)","options":[],"required":false,"pdf_field":""},{"help":"Strike off what is not applicable","type":"yes-no","label":"I. Do You want to opt for Floater Cover?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Amount for floater cover if opted","type":"amount","label":"Amount (₹):","options":[],"required":false,"pdf_field":""},{"help":"Details of fluctuating stocks","type":"text","label":"Stocks which fluctuate in value to be covered on (monthly) declaration basis:","options":[],"required":false,"pdf_field":""},{"help":"Strike off what is not applicable","type":"yes-no","label":"II. Do You want to opt for Declaration Policy?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"F. PREMIUM DETAILS","fields":[{"help":"Premium amount to be paid","type":"amount","label":"Payment Details - Amount","options":[],"required":true,"pdf_field":""},{"help":"Name of bank account holder for refund","type":"text","label":"Refund of Premium (Policyholder/Proposer) - Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"G. DECLARATION BY INSURED","fields":[{"help":"Full name","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Full address of witness","type":"text","label":"Address of Witness","options":[],"required":false,"pdf_field":""},{"help":"Full name of witness","type":"text","label":"Name of the Witness","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"enterprises with total value of insurable assets at a location exceeding ₹5 Crore but not exceeding ₹50 Crore, for Fire and Allied Perils insurance","attachments":["Detailed block plan showing various facilities (where applicable)"],"declarations":["The value of insurable assets is more than ₹5 Crore but less than ₹50 Crore and statements are true to the best of knowledge.","Any additions or alterations in the risk after submission must be conveyed immediately.","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 and future premiums will be similarly paid.","The company may call for documents to establish source of funds.","Details furnished are true and correct and changes will be informed within 30 days.","False or misleading information may lead to liability."],"dropped_labels":17},"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/icici-lombard-general-insurance/1999-proposal-form-for-icici-bharat-laghu-udyam-suraksha"}