{"id":2229,"title":"CLAIM FORM FOR CONTRACTOR'S PLANT & MACHINERY INSURANCE Notification of Physical Loss or Damage","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-insurance-retail.pdf","sha256":"34a6e9ffc687cf4932ff479b7e1c3248033fa3257ceb9f859ca19ff27ed9bfc8","pages":10,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage to contractor's plant and machinery under their insurance policy.","notes":["The issuance of this form is not to be taken as an admission of liability","Insured shall not enter into compromise/settlement without written permission of the Company","Completion and return of this form should not be delayed if any particulars cannot be immediately given; they may be forwarded later","Use original bills and documents as specified","Attach all relevant supporting documents as listed","For third-party property damage/bodily injury, file FIR if applicable","Surveyor will be appointed within 24 hours of claim reporting","Claim reference number will be provided upon claim registration","Politically Exposed Persons (PEPs) must be declared with details","RTGS/NEFT payments require original cancelled cheque and PAN card copy","Claims Manager or Surveyor will assess and approve repair/replacement details","Salvage value will be assessed where applicable","Turnaround time for claim processing is specified","All declarations must be signed and dated by the insured"],"title":"CLAIM FORM FOR CONTRACTOR'S PLANT & MACHINERY INSURANCE Notification of Physical Loss or Damage","submit":{"to":"Assigned Claims Manager (CSM) or Surveyor","how":"Submit documents to assigned CSM/Surveyor; claim intimation via toll-free number, email or website","address":"customersupport@icicilombard.com; https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx; Toll-free no.: 1800 2666"},"purpose":"claim","sections":[{"title":"Section I - Details of Insured and Loss","fields":[{"help":"","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"State date and time","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"i) Name","options":[],"required":true,"pdf_field":""},{"help":"Correspondence address of the insured","type":"text","label":"ii) Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"Contact phone number of the insured","type":"phone","label":"iii) Contact Number","options":[],"required":true,"pdf_field":""},{"help":"Date and time of loss or damage","type":"date","label":"a) When did the loss or damage occur? (State date and time)","options":[],"required":true,"pdf_field":""},{"help":"Date and time damage was discovered","type":"date","label":"b) When was the damage discovered? (State date & time)","options":[],"required":true,"pdf_field":""},{"help":"Location of the damage","type":"text","label":"c) State the site where the damage occurred.","options":[],"required":true,"pdf_field":""},{"help":"Address for inspection of loss","type":"text","label":"Address where the loss can be inspected.","options":[],"required":true,"pdf_field":""},{"help":"Name of damaged item","type":"text","label":"a) Item of the Inventory","options":[],"required":true,"pdf_field":""},{"help":"Sum insured for the item","type":"amount","label":"b) Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Type and capacity of machinery","type":"text","label":"c) Type of machinery & its capacity","options":[],"required":true,"pdf_field":""},{"help":"Manufacturer details as per maker's plate","type":"text","label":"d) Manufacturers name and year of manufacture. (Full details as on maker's plate to be given)","options":[],"required":true,"pdf_field":""},{"help":"Replacement cost including erection","type":"amount","label":"e) 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":true,"pdf_field":""},{"help":"State if guarantee period expired and date","type":"text","label":"a) Has the period of guarantee expired? If so, when?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if maintenance agreement exists","type":"yes-no","label":"b) 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":true,"pdf_field":""},{"help":"Detailed 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":true,"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":"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":"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":true,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of accident","options":[],"required":true,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Brief description of the accident (attach separate sheets if necessary)","options":[],"required":true,"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":"Indicate if reported and attach report","type":"yes-no","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":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe mitigation actions","type":"text","label":"What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":false,"pdf_field":""},{"help":"Details of other insurance policies","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 or damage","type":"date","label":"When did the loss or damage occur? (State date and time)","options":[],"required":true,"pdf_field":""},{"help":"Date and time damage was discovered","type":"date","label":"When was the damage discovered? (State date & time)","options":[],"required":true,"pdf_field":""},{"help":"Location of damage","type":"text","label":"State the site where the damage occurred","options":[],"required":true,"pdf_field":""},{"help":"Inspection address","type":"text","label":"Address where the loss can be inspected.","options":[],"required":true,"pdf_field":""},{"help":"Description of damaged item","type":"text","label":"a) What was damaged","options":[],"required":true,"pdf_field":""},{"help":"Inventory item name","type":"text","label":"b) Item of the Inventory","options":[],"required":true,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"c) Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Machinery type and capacity","type":"text","label":"d) Type of machinery & its capacity","options":[],"required":true,"pdf_field":""},{"help":"Manufacturer details","type":"text","label":"e) Manufacturers name and year of manufacture. (Full details as on maker's plate to be given)","options":[],"required":true,"pdf_field":""},{"help":"Replacement cost including erection","type":"amount","label":"f) 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":true,"pdf_field":""},{"help":"Guarantee expiry details","type":"text","label":"a) Has the period of guarantee expired? If so, when?","options":[],"required":null,"pdf_field":""},{"help":"Maintenance agreement status","type":"yes-no","label":"b) 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":true,"pdf_field":""},{"help":"Cause and replacement details; 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":true,"pdf_field":""},{"help":"Workshop details","type":"text","label":"Give the name and address of the workshop where repairs will be executed:","options":[],"required":null,"pdf_field":""},{"help":"Additional relevant information","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Persons (PEP) Declaration","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":true,"pdf_field":""},{"help":"Provide relationship and position details if Yes","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":"Claim Clause / Settlement of Claim Instructions","fields":[{"help":"Contact details and website for claim registration","type":"text","label":"Claim Intimation","options":[],"required":null,"pdf_field":""},{"help":"File FIR if applicable for third-party damage or fire","type":"text","label":"File an FIR","options":[],"required":null,"pdf_field":""},{"help":"Claims Manager will appoint surveyor within 24 hours","type":"text","label":"Surveyor Appointment","options":[],"required":null,"pdf_field":""},{"help":"Attach listed documents such as claim form, photos, reports, FIR, repair quotations, KYC, invoices etc.","type":"table","label":"Documents","options":[],"required":true,"pdf_field":""},{"help":"Repair/replacement details will be assessed and approved","type":"text","label":"Assessment Approval","options":[],"required":null,"pdf_field":""},{"help":"Amount assessed for damaged asset salvage value","type":"text","label":"Salvage","options":[],"required":null,"pdf_field":""},{"help":"Survey report within 15 days; claim decided within 7 days of survey report","type":"text","label":"Turnaround Time (TAT)","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declarations and Signature","fields":[{"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":"Signature of insured person","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Consent / Claim Application Form for Third Party Liability and Compromise","fields":[{"help":"Name of insured","type":"text","label":"Name of Insured","options":[],"required":true,"pdf_field":""},{"help":"Address of insured","type":"text","label":"i) Address","options":[],"required":true,"pdf_field":""},{"help":"Contact number","type":"phone","label":"ii) Contact Number","options":[],"required":true,"pdf_field":""},{"help":"Policy indemnity limits","type":"amount","label":"iii) Limits of Indemnity under the Policy","options":[],"required":true,"pdf_field":""},{"help":"Date of accident","type":"date","label":"Date of occurrence","options":[],"required":true,"pdf_field":""},{"help":"Accident location","type":"text","label":"Place of accident","options":[],"required":true,"pdf_field":""},{"help":"Type of accident","type":"text","label":"Nature of the accident","options":[],"required":true,"pdf_field":""},{"help":"Detailed accident description","type":"text","label":"Brief description of the accident (Attach separate sheets if necessary)","options":[],"required":true,"pdf_field":""},{"help":"Describe consequences","type":"text","label":"Details of loss / injury / death / damage","options":[],"required":true,"pdf_field":""},{"help":"Number of persons affected","type":"number","label":"Number of victims","options":[],"required":true,"pdf_field":""},{"help":"Details of victims","type":"text","label":"a) Give name/es, address/es occupation/s of such person/s","options":[],"required":true,"pdf_field":""},{"help":"Location of victims at accident time","type":"text","label":"b) State where such person were at the time of accident","options":[],"required":true,"pdf_field":""},{"help":"Medical treatment details","type":"text","label":"c) 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":"Claims made against insured","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":"Admit or deny liability","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":true,"pdf_field":""},{"help":"Explain reasons for settlement","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game plans/strategy for the same.","options":[],"required":null,"pdf_field":""},{"help":"Current negotiation status","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"Proposed liability amount","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":null,"pdf_field":""},{"help":"Evidence supporting compromise","type":"text","label":"What are the circumstances/evidence that favour a compromise?","options":[],"required":null,"pdf_field":""},{"help":"Comments on evidence sub-heads","type":"text","label":"Please indicate with due comments on each of the sub-heads below.","options":[],"required":null,"pdf_field":""},{"help":"Witness and evidence details","type":"text","label":"a) 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":null,"pdf_field":""},{"help":"Internal report details","type":"text","label":"b) Internal investigation report, if any","options":[],"required":false,"pdf_field":""},{"help":"Police report details","type":"text","label":"c) FIR / Investigation Report of police.","options":[],"required":false,"pdf_field":""},{"help":"Pollution report details","type":"text","label":"d) Pollution Control Board Report, if applicable.","options":[],"required":false,"pdf_field":""},{"help":"Medical or post mortem report","type":"text","label":"e) Post Mortem Report / Medical Certificate, if applicable.","options":[],"required":false,"pdf_field":""},{"help":"Survey report details","type":"text","label":"f) Survey / Investigation Report on the damaged Property, if any","options":[],"required":false,"pdf_field":""},{"help":"Legal or expert opinion","type":"text","label":"g) Legal opinion / Expert's opinion on admission of liability/appeal.","options":[],"required":false,"pdf_field":""},{"help":"Other relevant evidence","type":"text","label":"h) Any other circumstance/evidence.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if court case filed","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":null,"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":null,"pdf_field":""},{"help":"Attach court notices if any","type":"yes-no","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach court orders if any","type":"yes-no","label":"Has the court passed any interim or final order? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach court submitted documents","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":"Other claims details","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":"Additional evidence","type":"text","label":"Any other evidence in support of claim.","options":[],"required":false,"pdf_field":""},{"help":"Other insurance details","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":"Signature of insured","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Settlement amount and proof","type":"amount","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants? Please provide proof of the following (agreement, understanding, court order, court award etc)","options":[],"required":null,"pdf_field":""},{"help":"Court imposed liability and award copy","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you? Please provide copy of the court award.","options":[],"required":null,"pdf_field":""},{"help":"Defence costs incurred","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":null,"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":"Signature of insured","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","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the Payee.","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"attachment","label":"Please attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""},{"help":"Signature of account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["Assessment sheet / Survey report will be furnished within 15 days of receipt of claim form and documents","Claim will be decided within 7 days of receipt of the assessment sheet / survey report"],"applies_to":"Contractor's Plant & Machinery Insurance claims for physical loss or damage","attachments":["Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim, for instance, Service Engineer’s Report, Fire Brigade Report, etc.","FIR / Final Police investigation report wherever applicable","Repair/ replacement quotation, invoice and payment proofs for each and every item as claimed","Documents substantiating the quantum & value of the items under claim (if not repaired or reinstated)","Offer for retention of salvage, if any","KYC / NEFT Details as per AML guidelines","Invoice copy / Goods Receipt Note / Monetary Claim on carrier / Damage Certificate","Any other document which may be specified by the surveyor post completion of initial survey","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 an interest in the property are disclosed as per proposal or policy endorsement","No material information relevant to claim processing has been withheld or undisclosed","False or fraudulent statements or concealment 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 or UIDAI or other modes","If false or fraudulent statements are made in the Consent/Claim Application Form, claim shall be forfeited and policy void","Submission of documents or bank details does not imply admission of liability by the company","Customer agrees to indemnify ICICI Lombard for any losses arising from RTGS/NEFT transactions","Customer may terminate RTGS/NEFT facility with 15 days prior written notice to ICICI Lombard"],"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/2229-claim-form-for-contractor-s-plant-and-machinery-insurance-notification-of-physic"}