{"id":2023,"title":"PROPOSAL FORM FOR CLUB ROYALE HOME INSURANCE POLICY","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/20241007020-club-royale-form8c0007ff45fd68ff8a0df0055fa61c1b.pdf","sha256":"b5a79191ec78c49480a579dc60058a06fe0ad0db468f3feda1deb8ed078e875c","pages":8,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities proposing to purchase the Club Royale Home Insurance Policy to provide details about themselves, the property to be insured, and coverage options.","notes":["Please tick boxes wherever applicable","Failure to disclose material facts or providing misleading information may render the contract void","All items insured must be free of defects and in perfect condition at inception","Policy wordings are available on request","Read the Prospectus/Key Features Document/Policy Wordings before filling the form","Coverage starts only after proposal acceptance and premium payment","At least two sections of coverage must be selected to avail the policy","Use block letters where applicable","Attach original documents where required","Premium refund/claim payments will be made only through electronic transfer methods"],"title":"PROPOSAL FORM FOR CLUB ROYALE HOME INSURANCE POLICY","submit":{"to":"ICICI Lombard General Insurance Company Ltd","how":"post / e-mail / upload / in person","address":"Interface Building No. 16, 601-602, 6th Floor, New Link Road, Malad (West), Mumbai - 400 064; customersupport@icicilombard.com"},"purpose":"proposal","sections":[{"title":"A. INSURED DETAILS","fields":[{"help":"Enter full name with title","type":"text","label":"Name of Proposer Name: (Mr./Mrs./Ms./Dr.) First Name Middle Name Last Name","options":[],"required":null,"pdf_field":""},{"help":"Enter office address and code","type":"text","label":"Policy Issuing Office Address & Code","options":[],"required":null,"pdf_field":""},{"help":"Enter agent details if applicable","type":"text","label":"Intermediary/Agent Name & Code (if any) Name: (Mr./Mrs./Ms./Dr.) First Name Middle Name Last Name Code:","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Sex: M F","options":["M","F"],"required":null,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status: Single Married","options":["Single","Married"],"required":null,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation:","options":[],"required":null,"pdf_field":""},{"help":"Enter employer name if applicable","type":"text","label":"Employer(if any):","options":[],"required":false,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter city, town or village","type":"text","label":"City / Town / Village","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-Mail Address","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Contact No. Mobile","options":[],"required":null,"pdf_field":""},{"help":"Enter communication address","type":"text","label":"Communication Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":null,"pdf_field":""},{"help":"Enter GSTIN or UIN if applicable","type":"text","label":"GSTIN/UIN:","options":[],"required":false,"pdf_field":""},{"help":"Enter number of children","type":"number","label":"Number of Children","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee full name","type":"text","label":"Nomination: Nominee Name: First Name Middle Name Last Name","options":[],"required":false,"pdf_field":""},{"help":"Enter relationship to proposer","type":"text","label":"Relationship with the Proposer:","options":[],"required":false,"pdf_field":""},{"help":"Enter insurance start date in DDMMYYYY format","type":"date","label":"Period of insurance: From","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no and provide details if yes","type":"yes-no","label":"Are you or any of the proposed applicants a PEP* or Family member/ Close relatives/Associates of PEPs*? If yes, please give details (Nature of relationship and position held by PEP):","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Do you wish to avail policy documents in physical form Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter mobile number for physical documents if yes","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email ID for physical documents if yes","type":"email","label":"E mail ID","options":[],"required":false,"pdf_field":""},{"help":"Enter present and permanent address","type":"text","label":"Present & Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Enter authorized person details if nominee is minor","type":"text","label":"Authorized person for Minor Nominee","options":[],"required":false,"pdf_field":""},{"help":"Enter bank details for refund/claim payments","type":"text","label":"Bank Details","options":[],"required":false,"pdf_field":""},{"help":"Select type of proposer","type":"choice","label":"Type of Proposer Individual Partnership firm MSME/SME Company Govt. Others","options":["Individual","Partnership firm","MSME/SME","Company","Govt.","Others"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"B. COVER DETAILS AND PROPERTY INFORMATION","fields":[{"help":"Select yes or no and provide details if yes","type":"yes-no","label":"Is there any policy in place for the same property? If Yes, please provide the details:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full postal address and pin code","type":"text","label":"Location of Home Building - full postal address with Pin Code.","options":[],"required":true,"pdf_field":""},{"help":"Select building type","type":"choice","label":"Is it in a multi-storey building or is it a standalone house?","options":["Multi-storey building","Standalone house"],"required":null,"pdf_field":""},{"help":"Enter floor number if applicable","type":"number","label":"In case of multi-storey building, please provide the floor number of Your house","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Is there a basement to Your house?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amount required to construct home building at policy commencement date","type":"amount","label":"Sum Insured (SI) for Home Building","options":[],"required":true,"pdf_field":""},{"help":"Enter carpet area in square metres","type":"number","label":"Carpet area of structure of Home in square metres","options":[],"required":true,"pdf_field":""},{"help":"Enter prevailing rate of cost of construction per square metre","type":"amount","label":"Rate of Cost of Construction per square metre at the policy","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured for residential structure and additional structures","type":"amount","label":"Details of Home Building a. SI for residential structure of Your Home including fittings and fixtures (in ₹): b. SI for additional structures (in ₹): Additional Structure Sum Insured (in ₹)","options":[],"required":true,"pdf_field":""},{"help":"List all insured parties and financiers","type":"text","label":"Policy to be issued in favour of (list out all the parties who have insurable interest) including the financial institutions: Insured 1, Insured 2, Insured 3, Insured 4, Financier Name(if applicable):","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"C. DETAILS OF HOME CONTENTS","fields":[{"help":"Provide item wise sum insured for furniture, electrical/electronic, others","type":"table","label":"If You want to opt out of in-built cover for General Contents and want to have higher Sum Insured or If You have opted for Home Contents Only cover, please provide item wise Sum Insured for General Contents.","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured for contents in basement if any","type":"amount","label":"In case of Basement, If there are contents in it, please provide the Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Select age category of home building","type":"choice","label":"Age of Home Building","options":["Less than 5 years","5-10 years","10-20 years","Above 20 years"],"required":null,"pdf_field":""},{"help":"Enter sum insured and number of months for loss of rent and/or rent for alternative accommodation","type":"amount","label":"Loss of Rent: I. Sum Insured II. Number of Months Rent for Alternative Accommodation: I. Sum Insured II. Number of Months Cover for (Please Tick) Loss of Rent Rent for Alternative Accommodation","options":["Loss of Rent","Rent for Alternative Accommodation"],"required":false,"pdf_field":""},{"help":"Provide spouse name and ages if personal accident cover selected","type":"text","label":"If Yes, Name & age of Your spouse: Your age Spouse Name: Spouse Age","options":[],"required":false,"pdf_field":""},{"help":"Attach list of valuable items and valuation certificate if applicable","type":"attachment","label":"If Yes, please attach list of items and Sum Insured: Valuation certificate attached? No Yes","options":["No","Yes"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"D. ADDITIONAL COVERS AND DETAILS","fields":[{"help":"Enter sum insured for burglary and theft","type":"amount","label":"Burglary and Theft Sum Insured (₹)","options":[],"required":false,"pdf_field":""},{"help":"Enter number of domestic employees and liability sum insured","type":"number","label":"Liability - No of Domestic employees at the insured location/s, INR","options":[],"required":false,"pdf_field":""},{"help":"Provide nominee name and sum insured for personal accident cover","type":"text","label":"Personal Accident - Name of assignee/nominee, SI, No. of domestic employee at insured location","options":[],"required":false,"pdf_field":""},{"help":"Provide any additional information relevant to underwriting","type":"text","label":"Additional Information","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"E. DECLARATIONS AND SIGNATURES","fields":[{"help":"Sign the form","type":"signature","label":"Signature of the Insured Person / Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signature in DDMMYYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent/intermediary to sign and provide code","type":"signature","label":"Name & signature of agent/intermediary Code","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and agent"}],"deadlines":["Inform the insurer of any changes in details immediately, not later than 30 days"],"applies_to":"Club Royale Home Insurance Policy","attachments":["Valuation certificate (if opting for Valuable Contents cover above ₹5 Lakh or individual item value exceeds ₹1 Lakh)","List of valuable items (if opting for Valuable Contents cover)","Cancelled cheque leaf (if premium cheque is not paid from the bank account provided)"],"declarations":["The form content and policy terms have been explained and understood by the proposer","Consent is given to verify identity/address through KYC registries","Premiums are paid from legally acquired sources and future premiums will be paid similarly","Details provided are true and correct to the best of knowledge and any changes will be informed within 30 days","False or misleading information may lead to liability and policy cancellation","Insurance is effective only after acceptance of application and premium payment","The company may record telephonic transactions and use voice logs","The company may cancel the policy if premium payment is not realized"],"dropped_labels":17},"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/2023-proposal-form-for-club-royale-home-insurance-policy"}