{"id":2003,"title":"PROPOSAL FORM PREMISES POLLUTION LIABILITY INSURANCE","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/12-premises-pollution-liability-insurance-retail8c0007ff45fd68ff8a0df0055fa61687.pdf","sha256":"1fc7ee5bf4d64f7c24e8a9938a8bb0d1a45e475ee0bf2df110e030e71878dfbb","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by a policyholder to apply for premises pollution liability insurance by providing necessary details and declarations.","notes":["Answer all questions fully and correctly; write N.A. if not applicable.","The form must be signed and dated by a principal of the policyholder.","Use additional sheets if more space is needed, indicating the question number.","Insurance liability starts only after proposal acceptance and premium payment.","The statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938 applies."],"title":"PROPOSAL FORM PREMISES POLLUTION LIABILITY INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"General Instructions and Nominee Details","fields":[{"help":"Select Yes or No to receive physical policy documents","type":"choice","label":"Do you wish to avail policy documents in physical form","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the full name of the nominee","type":"text","label":"Nominee Name","options":[],"required":null,"pdf_field":""},{"help":"Specify the nominee's relationship to the insured","type":"text","label":"Relationship with the Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Address, Authorized Person and Insurance Details","fields":[{"help":"Provide full present and permanent address","type":"text","label":"Present & Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Name of authorized person if nominee is a minor","type":"text","label":"Authorized person for Minor Nominee","options":[],"required":null,"pdf_field":""},{"help":"Provide bank details for transactions","type":"text","label":"Bank Details","options":[],"required":null,"pdf_field":""},{"help":"List other insurance policies covering the same risks","type":"text","label":"Details of Multiple/Other insurance covering same risks with any other Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"Select the type of proposer","type":"choice","label":"Type of Proposer","options":["Individual","Partnership firm","MSME/SME","Company","Govt.","Others"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Refund of Premium Bank Details","fields":[{"help":"Name of the bank account holder for premium refund","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No.","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Signatures and Declaration","fields":[{"help":"Enter full name of the proposer","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"If applicable, specify relationship with proposer","type":"text","label":"Relationship with Proposer","options":[],"required":null,"pdf_field":""},{"help":"Provide address of the witness","type":"text","label":"Address of Witness","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the witness","type":"text","label":"Name of the Witness","options":[],"required":null,"pdf_field":""},{"help":"Proposer must sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Witness must sign here","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder / witness / person filling on behalf"}],"deadlines":["Inform insurer of any changes immediately, not later than 30 days"],"applies_to":"Premises Pollution Liability Insurance","attachments":["Attach additional sheets if space is insufficient to complete details"],"declarations":["The proposer must disclose all material facts and not suppress any material information.","The policy shall become voidable if any untrue or incorrect statement or non-disclosure is made.","The proposer agrees to abide by all terms and conditions of the insurance policy.","The insurance cover commences only after acceptance of the proposal and payment of premium.","The proposer consents to verification of identity/address through KYC processes.","Premiums are paid from legally acquired sources of income.","The proposer understands the insurer may call for documents to establish source of funds.","The proposer declares that all information provided is true and correct to the best of their knowledge.","The proposer is aware of penalties for providing false or misleading information.","The statutory warning prohibits rebates on commission or premium except as allowed by insurer's published prospectuses."],"dropped_labels":0},"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/2003-proposal-form-premises-pollution-liability-insurance"}