{"id":2224,"title":"CLAIM FORM FOR CONTRACTOR'S PLANT & MACHINERY (First Loss Basis) PACKAGE POLICY","purpose":"claim","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/claim-form-for-contractor's-plant-machinery-(first-loss-basis)-package-policy-commercial.pdf","sha256":"28139bf2c198a65026f39be5195ecc9320038ad2ebf9859b7d44f5f645fe7c78","pages":9,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage under the Contractor's Plant & Machinery insurance on a first loss basis.","notes":["The issuance of this form is not to be taken as an admission of liability.","Answer all questions fully.","Attach separate sheets if necessary for detailed descriptions.","Provide full details as on maker's plate for machinery.","Attach all relevant reports and documents as required.","Use original blank cancelled cheque and PAN card copy for EFT mandate.","Submission of documents or bank details does not imply admission of liability.","Notices may be given by hand, email, website or post to last known address.","Terms and conditions governed by laws of India; legal proceedings in Mumbai courts.","Refund any excess amount credited in error within 7 days of notification.","RTGS/NEFT facility activation may take up to 15 days after receipt of mandate form."],"title":"CLAIM FORM FOR CONTRACTOR'S PLANT & MACHINERY (First Loss Basis) PACKAGE POLICY","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section I - Details of Insured and Loss","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of loss or damage","type":"date","label":"When did the loss or damage occur? (State date and time)","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time when damage was discovered","type":"date","label":"When was the damage discovered? (State date & time)","options":[],"required":null,"pdf_field":""},{"help":"Provide location of damage","type":"text","label":"State the site where the damage occurred.","options":[],"required":null,"pdf_field":""},{"help":"Provide address for inspection","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe damaged item","type":"text","label":"What was damaged","options":[],"required":null,"pdf_field":""},{"help":"Specify inventory item damaged","type":"text","label":"Item of the Inventory","options":[],"required":null,"pdf_field":""},{"help":"Provide sum insured for the item","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Provide type and capacity of machinery","type":"text","label":"Type of machinery & its capacity","options":[],"required":null,"pdf_field":""},{"help":"Provide manufacturer details exactly as on maker's plate","type":"text","label":"Manufacturers name and year of manufacture. (Full details as on maker's plate to be given)","options":[],"required":null,"pdf_field":""},{"help":"Provide replacement cost including erection","type":"amount","label":"What is the cost of replacement of the machine by a new machine of the same size and capacity including its erection cost?","options":[],"required":null,"pdf_field":""},{"help":"State guarantee expiry date if applicable","type":"text","label":"Has the period of guarantee expired? If so, when?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have any maintenance agreement with the manufacturer/repairer?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide estimated loss amount","type":"amount","label":"What is the estimated amount of loss or damage?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section I continued - Cause and Repair Details","fields":[{"help":"Explain cause and whether replacement is needed; attach sketch if possible","type":"text","label":"What was the cause of the damage and how did it occur? Is replacement required? (This question must be answered in detail and a sketch given wherever possible)","options":[],"required":null,"pdf_field":""},{"help":"Provide workshop details for repairs","type":"text","label":"Give the name and address of the workshop where repairs will be executed:","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Section II - Third Party Liability","fields":[{"help":"Provide details of indemnity cover","type":"text","label":"Indemnity Cover under this section","options":[],"required":null,"pdf_field":""},{"help":"Date and time of accident","type":"date","label":"Date and time of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Brief description of the accident (attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Date when accident was first known","type":"date","label":"When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of reporting authority and attach report copy","type":"text","label":"Has the accident been reported to any authority? If so, state by whom and attach a copy of the report submitted (like meteorological report, pollution control report etc.)","options":[],"required":null,"pdf_field":""},{"help":"Describe mitigation actions taken","type":"text","label":"What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":false,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Section III - Increased Cost of Working","fields":[{"help":"Details of indemnity cover","type":"text","label":"Indemnity Cover under this section","options":[],"required":null,"pdf_field":""},{"help":"Date and time of loss","type":"date","label":"When did the loss or damage occur? (State date and time)","options":[],"required":null,"pdf_field":""},{"help":"Date and time damage was discovered","type":"date","label":"When was the damage discovered? (State date & time)","options":[],"required":null,"pdf_field":""},{"help":"Location of damage","type":"text","label":"State the site where the damage occurred","options":[],"required":null,"pdf_field":""},{"help":"Inspection address","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe damaged item","type":"text","label":"What was damaged","options":[],"required":null,"pdf_field":""},{"help":"Inventory item damaged","type":"text","label":"Item of the Inventory","options":[],"required":null,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Type and capacity of machinery","type":"text","label":"Type of machinery & its capacity","options":[],"required":null,"pdf_field":""},{"help":"Manufacturer details as per maker's plate","type":"text","label":"Manufacturers name and year of manufacture. (Full details as on maker's plate to be given)","options":[],"required":null,"pdf_field":""},{"help":"Replacement cost including erection","type":"amount","label":"What is the cost of replacement of the machine by a new machine of the same size and capacity including its erection cost","options":[],"required":null,"pdf_field":""},{"help":"Guarantee expiry date if applicable","type":"text","label":"Has the period of guarantee expired? If so, when?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have any maintenance agreement with the manufacturer/repairer","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Estimated loss amount","type":"amount","label":"What is the estimated amount of loss or damage","options":[],"required":null,"pdf_field":""},{"help":"Explain cause and replacement need; attach sketch if possible","type":"text","label":"What was the cause of the damage and how did it occur? Is replacement required? (This question must be answered in detail and a sketch given wherever possible","options":[],"required":null,"pdf_field":""},{"help":"Workshop details for repairs","type":"text","label":"Give the name and address of the workshop where repairs will be executed:","options":[],"required":null,"pdf_field":""},{"help":"Other relevant information","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"PEP Declaration and Consent","fields":[{"help":"Select yes or no","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member / Close relatives / Associates close relative of a PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details 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":"insured"},{"title":"Declarations by Insured","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Application / Consent Requisition Form","fields":[{"help":"","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Provide indemnity limits","type":"amount","label":"Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Date of accident","type":"date","label":"Date of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe accident nature","type":"text","label":"Nature of the accident","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Brief description of the accident (Attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Describe consequences","type":"text","label":"Details of loss / injury / death / damage","options":[],"required":null,"pdf_field":""},{"help":"Number of persons affected","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Details of victims","type":"text","label":"Give name/es, address/es occupation/s of such person/s","options":[],"required":null,"pdf_field":""},{"help":"Location of victims at accident time","type":"text","label":"State where such person were at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Medical treatment details","type":"text","label":"Have the injured persons been removed to hospital or medically attended? If so, give particulars","options":[],"required":null,"pdf_field":""},{"help":"Property damage details","type":"text","label":"Has the accident caused damage to property? If so, give name/s and address/es of the owner/s of the property and full description of the property and state the nature and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Claim details and attachments","type":"text","label":"Has any person made any claim upon you? If so, state by whom and give full particulars (if claim has been made in writing, attach a copy of the notification received and of the bill, if submitted).","options":[],"required":null,"pdf_field":""},{"help":"Estimated liability amount","type":"amount","label":"Estimated quantum of liability under (ii) and (iii) above","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you agree that you are liable for the accident and the consequential loss/damage either to persons/property or livestock?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain reasons for compromise","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game plans/strategy for the same.","options":[],"required":false,"pdf_field":""},{"help":"Current negotiation status","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":false,"pdf_field":""},{"help":"Proposed liability amount","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":false,"pdf_field":""},{"help":"Evidence supporting compromise","type":"text","label":"What are the circumstances/evidence that favour a compromise?","options":[],"required":false,"pdf_field":""},{"help":"Provide comments on evidence items below","type":"text","label":"Please indicate with due comments on each of the sub-heads below.","options":[],"required":false,"pdf_field":""},{"help":"Attach witness statements and evidence","type":"text","label":"Statement from witness, sketch plans, photographs, visual records of evidence / circumstance, video recording to establish the liability. Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":false,"pdf_field":""},{"help":"Attach internal investigation report","type":"attachment","label":"Internal investigation report, if any","options":[],"required":false,"pdf_field":""},{"help":"Attach FIR or police report","type":"attachment","label":"FIR / Investigation Report of police.","options":[],"required":false,"pdf_field":""},{"help":"Attach pollution control report if relevant","type":"attachment","label":"Pollution Control Board Report, if applicable.","options":[],"required":false,"pdf_field":""},{"help":"Attach post mortem or medical certificate if relevant","type":"attachment","label":"Post Mortem Report / Medical Certificate, if applicable.","options":[],"required":false,"pdf_field":""},{"help":"Attach survey or investigation report","type":"attachment","label":"Survey / Investigation Report on the damaged Property, if any","options":[],"required":false,"pdf_field":""},{"help":"Attach legal or expert opinion","type":"attachment","label":"Legal opinion / Expert's opinion on admission of liability/appeal.","options":[],"required":false,"pdf_field":""},{"help":"Other relevant evidence","type":"text","label":"Any other circumstance/evidence.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the accident?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Status and next hearing date","type":"text","label":"If yes, what is the present status of the proceedings? Also give the next date of hearing.","options":[],"required":false,"pdf_field":""},{"help":"Attach court notices or summons","type":"attachment","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":[],"required":false,"pdf_field":""},{"help":"Attach court orders","type":"attachment","label":"Has the court passed any interim or final order? If yes, please provide copies of the same.","options":[],"required":false,"pdf_field":""},{"help":"Attach all court documents submitted","type":"attachment","label":"Also provide copies of all the documents that have been submitted to the Court either by you or the Claimants, and copies of all the documents.","options":[],"required":false,"pdf_field":""},{"help":"Provide details of other claims","type":"text","label":"Details of claims if any preferred by the affected party / Insured for the same loss from another source.","options":[],"required":false,"pdf_field":""},{"help":"Other supporting evidence","type":"text","label":"Any other evidence in support of claim.","options":[],"required":false,"pdf_field":""},{"help":"Details of other insurance policies","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","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":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Settlement Form","fields":[{"help":"Provide settlement amount","type":"amount","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants?","options":[],"required":null,"pdf_field":""},{"help":"Attach proof of settlement","type":"attachment","label":"Please provide proof of the following (agreement, understanding, court order, court award etc)","options":[],"required":null,"pdf_field":""},{"help":"Court imposed liability amount","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you?","options":[],"required":false,"pdf_field":""},{"help":"Attach court award copy","type":"attachment","label":"Please provide copy of the court award.","options":[],"required":false,"pdf_field":""},{"help":"Provide total defence costs","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","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":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Attach original cancelled cheque with signature","type":"attachment","label":"Attach an Original Blank Cancelled Cheque signed by the Payee","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"attachment","label":"Attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Contractor's Plant & Machinery insurance - First Loss Basis","attachments":["Copy of report submitted to authority (e.g. meteorological report, pollution control report etc.)","Separate sheets if necessary for accident description","Notification of claim or bill if claim made in writing","Internal investigation report, if any","FIR / Investigation Report of police","Pollution Control Board Report, if applicable","Post Mortem Report / Medical Certificate, if applicable","Survey / Investigation Report on the damaged Property, if any","Legal opinion / Expert's opinion on admission of liability/appeal","Copies of court notices, summons, orders, and documents submitted","Proof of settlement (agreement, court order, court award etc.)","Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having interest in the property are disclosed as per proposal or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to claim processing has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of claim form or documents does not constitute admission of liability by the company.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes.","Completion and return of claim application/consent form should not be delayed if particulars are not immediately available.","Insured shall not enter into compromise/settlement without written permission of the company.","False or fraudulent statements in claim application or further declarations will forfeit claim and void policy.","Receipt of consent/claim application form does not constitute approval for settlement; company reserves right to grant permission.","Terms and conditions for payments through RTGS/NEFT are agreed upon by the customer."],"dropped_labels":1},"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/2224-claim-form-for-contractor-s-plant-and-machinery-first-loss-basis-package-policy"}