{"id":2009,"title":"PROPOSAL FORM CYBER SECURE 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/3-cyber-liability-lnsurance-retail8c0007ff45fd68ff8a0df0055fa6136f.pdf","sha256":"435a61242568611c987ecd79f5d22cba785a085a6bbd4d843f5ff12796d0aae0","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities applying for Cyber Liability Insurance with ICICI Lombard General Insurance Company Limited. The proposer fills this form to provide necessary information for underwriting the policy.","notes":["Statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938 applies.","The declaration does not confirm issuance of policy or assumption of risk.","Use accurate and truthful information to avoid penalties."],"title":"PROPOSAL FORM CYBER SECURE INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"proposal","sections":[{"title":"Policy Document Preference and Nominee Details","fields":[{"help":"","type":"choice","label":"Do you wish to avail policy documents in physical form","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nominee Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address, Authorized Person and Bank Details","fields":[{"help":"Enter full address","type":"text","label":"Present & Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"If nominee is minor, provide authorized person's details","type":"text","label":"Authorized person for Minor Nominee","options":[],"required":null,"pdf_field":""},{"help":"Provide bank details for refund of premium","type":"text","label":"Bank Details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","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":"proposer"},{"title":"Cyber Security and Privacy Exposures","fields":[{"help":"","type":"yes-no","label":"Is the Company's business continuity plan formalized and tested?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have antivirus software on all computer systems which are updated in accordance with the software providers' recommendations?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have firewalls and intrusion monitoring detection in force to prevent unauthorized access?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are all employees assigned specified rights, privileges and unique user ID and passwords, which are changed periodically?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company terminate all associated computer system access and user accounts as part of the regular exit process when an employee leaves the company?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are connections from laptop, mobile devices, and remote users into the Company's system secured?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"If 'No', please describe exceptions","type":"yes-no","label":"Is all valuable and / or sensitive data backed-up by the Company every day?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Specify duration","type":"text","label":"How long are back-up tapes stored before being overwritten?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have and enforce policies concerning when internal and external communication should be encrypted?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is personally identifiable information stored on laptop computers and portable media (flash drives, back-up tapes) protected by encryption?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Privacy Exposures","fields":[{"help":"","type":"yes-no","label":"Does the Company collect, maintain or process personal information of clients as part of its professional services?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Tick all that apply","type":"checkbox","label":"If 'Yes', please indicate the type of information which is collected and stored?","options":["Social Security Numbers","Personal Health Data","Credit Card Information","Bank Account Information","Employee Information","Other (Please Describe)"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have a designated privacy officer who has responsibility for meeting the Company's worldwide obligation under privacy and data protection laws?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Provide name or designation","type":"text","label":"If 'No', who is responsible for management of, and compliance with the Company's privacy policies?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company share personal information gathered from customers with Consultants or third parties?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"If 'Yes', is explicit consent of the customers taken before sharing such information?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company conduct regular reviews of the consultant and third party service providers to ensure that they meet the company's requirement for personal information in their custody?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Media","fields":[{"help":"","type":"yes-no","label":"Does the Company have a designated officer who has responsibility for monitoring the content of the website from a legal perspective?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"If 'Yes', please provide details","type":"yes-no","label":"Does the Company have a formal procedure for editing or removing controversial, offensive or infringing material?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company offer chat-room or user group discussion facilities through its website?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have a review process in place to screen material displayed on its website for copyright/trademark infringement and slander/libel?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company display material created by third parties (e.g. videos, music, and blogs)?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details for Refund of Premium","fields":[{"help":"Enter bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Name as per bank records","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":""}],"filled_by":"proposer"},{"title":"Signatures and Declarations","fields":[{"help":"","type":"text","label":"Name of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Proposer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of Witness","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Witness","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer and witness"}],"deadlines":[],"applies_to":"Cyber Liability Insurance policies","attachments":[],"declarations":["The person filling the form for the proposer declares having explained the form and connected documents to the proposer who understands and agrees to the terms.","The person filling the form in vernacular or for illiterate proposer declares having explained the form in the specified language and recorded answers correctly with proposer’s thumb impression.","The proposer declares having fully understood the contents and significance of the proposed contract."],"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/2009-proposal-form-cyber-secure-insurance"}