{"id":2231,"title":"CLAIM FORM FOR CLUB ROYALE HOME INSURANCE 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/20221221010-club-royale-home-insurance---claim-form-policy-wording-30-12-20228c0007ff45fd68ff8a0df0055f9a7f58.pdf","sha256":"2386bec1af319052552919d05aed4858739e16767b965de1df06e64fdb6e9d08","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to notify and claim for physical loss or damage under the Club Royale Home Insurance Policy.","notes":["Use original bills only","Attach photographs or videos of damaged property","File an FIR in case of third-party property damage, bodily injury, fire etc. as per policy terms","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting","Submit all relevant documents to assigned Claims Service Manager or Surveyor","Assessment and approval of repair/replacement details will be done by CSM/surveyor","Salvage value will be considered where applicable","Policies issued on reinstatement value basis have different claim conditions","Use block letters to fill the form"],"title":"CLAIM FORM FOR CLUB ROYALE HOME INSURANCE POLICY","submit":{"to":"Assigned Claims Service Manager (CSM) or Surveyor","how":"Submit documents to assigned CSM/Surveyor via claim portal or email","address":"Mailing Address: Interface Building No. 16, 601-602, 6th Floor, New Link Road, Malad (West), Mumbai - 400 064; Email: customersupport@icicilombard.com"},"purpose":"claim","sections":[{"title":"Details of Insured and Contact","fields":[{"help":"","type":"text","label":"Name: (Mr./Mrs./Ms./Dr.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Other Insurance and Mortgagee","fields":[{"help":"Attach copies of other insurance policies if applicable","type":"text","label":"Details of other Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No. (s).","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter start date of policy period","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Loss","fields":[{"help":"Date and time when loss occurred","type":"date","label":"Date and Time of","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the affected insured item","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"State how the premises was used at time of loss","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":null,"pdf_field":""},{"help":"If no, give reasons","type":"yes-no","label":"Has the Fire / Loss been reported to Fire Brigade?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Full name of injured or deceased person","type":"text","label":"Name of the Person Injured/Died","options":[],"required":null,"pdf_field":""},{"help":"Location where injury or death occurred","type":"text","label":"Place of injury/ Death","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Details of the accident","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide police station details","type":"yes-no","label":"Whether reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide hospital name and address","type":"yes-no","label":"Was the injured /deceased person moved to hospital immediately after the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If no, give reasons","type":"yes-no","label":"Has the Fire / Loss been reported to Police?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Politically Exposed Persons (PEP) Declaration","fields":[{"help":"PEP means Politically Exposed Persons as defined","type":"choice","label":"Are you or any of the proposed applicants a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe relationship and position","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Fine Art and Valuables Claim Details","fields":[{"help":"Attach FIR copy if yes","type":"yes-no","label":"Has a complaint been lodged with the police? If so, by whom and when and at which police station? Attach copy of FIR","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the property occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time last occupied","type":"date","label":"If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"Duration property was unoccupied","type":"text","label":"For how long have the property been unoccupied?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if theft suspected","type":"text","label":"Is anybody suspected of theft? If so, state full details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured the sole owner of: The Property lost or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of other owners","type":"text","label":"If no, the Property belongs to whom ?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured responsible for repairs to the Property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"State the total value of /item (s) in the Dwelling at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed list in Annexure I","type":"attachment","label":"Value and description of Contents lost, to be given In the Annexure I.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Burglary and/or Theft Claim Details","fields":[{"help":"","type":"text","label":"Which portion of the Dwelling effected by the entry/exit?","options":[],"required":null,"pdf_field":""},{"help":"Attach FIR copy if yes","type":"yes-no","label":"Has a complaint been lodged with the police? If so, by whom and when and at which police station? Attach copy of FIR","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the property occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time last occupied","type":"date","label":"If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"Duration property was unoccupied","type":"text","label":"For how long have the property been unoccupied?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if theft suspected","type":"text","label":"Is anybody suspected of theft? If so, state full details.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured the sole owner of: The Property lost or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of other owners","type":"text","label":"If no, the Property belongs to whom ?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured responsible for repairs to the Property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"State the total value of /item (s) in the Dwelling at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed list in Annexure I","type":"attachment","label":"Value and description of Contents lost, to be given In the Annexure I.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Loss of Cash in Safe","fields":[{"help":"","type":"text","label":"Which portion of the Dwelling effected by the entry/exit?","options":[],"required":null,"pdf_field":""},{"help":"Attach FIR copy if yes","type":"yes-no","label":"Has a complaint been lodged with the police? If so, by whom and when and at which police station? Attach copy of FIR","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the property occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time last occupied","type":"date","label":"If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"Duration property was unoccupied","type":"text","label":"For how long have the property been unoccupied?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if theft suspected","type":"text","label":"Is anybody suspected of theft? If so, state full details.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured the sole owner of: The Property lost or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of other owners","type":"text","label":"If no, the Property belongs to whom ?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured responsible for repairs to the Property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"State the total value of /item (s) in the Dwelling at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed list in Annexure I","type":"attachment","label":"Value and description of Contents lost, to be given In the Annexure I.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information.","options":[],"required":false,"pdf_field":""},{"help":"Date and time loss was discovered","type":"date","label":"Date and Time of when loss was discovered","options":[],"required":null,"pdf_field":""},{"help":"Amount of cash lost","type":"amount","label":"What was the amount carried?","options":[],"required":null,"pdf_field":""},{"help":"Name of person responsible for money","type":"text","label":"In whose custody was the money at the time of loss?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Personal Liability Claim","fields":[{"help":"Describe consequences of accident","type":"text","label":"Particulars of consequences of the accident:","options":[],"required":null,"pdf_field":""},{"help":"Details of loss or injury","type":"text","label":"Details of loss / injury / death /damage","options":[],"required":null,"pdf_field":""},{"help":"Number of persons injured or affected","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Columns: Name (Mr./Mrs./Ms./Dr.), First Name, Middle Name, Last Name, Address, Occupation","type":"table","label":"Give name/s, address/es and occupation/s of such person/s","options":[],"required":null,"pdf_field":""},{"help":"Location of persons 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":"","type":"yes-no","label":"Has the Accident caused damage to property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Columns: Name (Mr./Mrs./Ms./Dr.), First Name, Middle Name, Last Name, Address, Nature and extent of damage","type":"table","label":"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":"Details of claims made against you","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 (3) and (7) above","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Recreational Bicycle Claim","fields":[{"help":"Describe loss details","type":"text","label":"Details of loss:","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Particulars pertaining to the accident:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the Accident caused damage to property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Columns: Name (Mr./Mrs./Ms./Dr.), First Name, Middle Name, Last Name, Address, Nature and extent of damage","type":"table","label":"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":"Details of claims made against you","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 (3) and (7) above","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Pet Claim","fields":[{"help":"Details about your pet","type":"text","label":"About your Pet","options":[],"required":null,"pdf_field":""},{"help":"Veterinarian to fill pet's condition","type":"text","label":"Your Pet’s condition(Filled by the vet)","options":[],"required":null,"pdf_field":""},{"help":"Details of previous veterinary care","type":"text","label":"Previous Veterinary practices","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder and vet"},{"title":"Marine Transit Claim","fields":[{"help":"New residence address for transit claim","type":"text","label":"Address of the New Residence","options":[],"required":null,"pdf_field":""},{"help":"Attach FIR copy if yes","type":"yes-no","label":"Has a complaint been lodged with the police? If so, by whom and when and at which police station? Attach copy of FIR","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide detailed list in Annexure I","type":"attachment","label":"Value and description of Contents lost, to be given In the Annexure I.","options":[],"required":null,"pdf_field":""},{"help":"Provide transport details and receipts","type":"text","label":"Details of Mode of conveyance, Goods Receipt No. / Railway Receipt No./ Airway Bill No. for transit distance","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Mechanical/Electrical Appliances Breakdown Claim","fields":[{"help":"Date when appliance broke down","type":"date","label":"Date of Breakdown","options":[],"required":null,"pdf_field":""},{"help":"Describe breakdown event","type":"text","label":"Details of the event of loss:","options":[],"required":null,"pdf_field":""},{"help":"Age of the appliance(s) in years","type":"text","label":"Age of the appliance(s):","options":[],"required":null,"pdf_field":""},{"help":"Provide detailed list in Annexure I","type":"attachment","label":"Value and description of Contents lost, to be given In the Annexure I.","options":[],"required":null,"pdf_field":""},{"help":"Address where loss occurred","type":"text","label":"Address of the Dwelling at which loss","options":[],"required":null,"pdf_field":""},{"help":"Inspection address if different","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe extent of loss","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Annexure I - List of Contents Lost","fields":[{"help":"List each lost item with description and value","type":"table","label":"S No, Description of item, Value (INR)","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":["Inform changes in details immediately, not later than 30 days","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":"Club Royale Home Insurance Policy claims for physical loss or damage","attachments":["Copies of other insurance policies if applicable","Copy of FIR if complaint lodged with police","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim (e.g. Service Engineer’s Report, Fire Brigade Report)","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for each item claimed","Documents substantiating the quantum & value of 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 specified by the surveyor post initial survey","Annexure I listing value and description of contents lost"],"declarations":["The information given in this claim form is true, correct and complete","All persons having interest in the property are disclosed as per proposal or policy endorsement","No material information relevant to claim processing has been withheld","False or fraudulent statements or concealment of 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 through Central KYC Registry or UIDAI or other modes","Company has the right to call for documents to establish source of funds","Details furnished are true and changes will be informed within 30 days","False or misleading information may lead to liability"],"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/2231-claim-form-for-club-royale-home-insurance-policy"}