{"id":2234,"title":"CLAIM FORM FOR EVENT INSURANCE","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/event-insurance-policy---commercial.pdf","sha256":"23af594e0014ba70cf8e76df0dce97a132d4f7d3fffd9be35137d0d4685152a0","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to claim insurance for event-related losses or damages under the event insurance policy.","notes":["The issuance of this form is not an admission of liability.","Complete and return the form without delay; missing particulars can be forwarded later.","Attach original blank cancelled cheque and PAN card copy for EFT payment option.","Use the specified date and time formats (DD/MM/YYYY and HH:MM AM/PM).","Attach copies of all relevant documents, including court documents if applicable.","The form includes a section for Electronic Fund Transfer mandate with terms and conditions."],"title":"CLAIM FORM FOR EVENT INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064; E-mail: customersupport@icicilombard.com"},"purpose":"claim","sections":[{"title":"Details of Insured","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":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Limits of Indemnity under the Policy","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Event","fields":[{"help":"Use format DD/MM/YYYY and time in HH:MM AM/PM","type":"date","label":"Date and time of proposed Event","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Location of the proposed Event","options":[],"required":null,"pdf_field":""},{"help":"Specify details if yes","type":"text","label":"Whether any approvals for the insured event taken from government or any regulatory authorities. If yes then kindly give details of approval from the respective authorities.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Approx. number of audience to be present in the proposed event.","options":[],"required":null,"pdf_field":""},{"help":"Specify duration (e.g. hours, days)","type":"text","label":"Duration of the event.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Other Insurance","fields":[{"help":"Attach copies of such policies if insurance is effected with other companies","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":"Start date of policy period","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Persons as defined in the form","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answered Yes above","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss and Damage Details","fields":[{"help":"","type":"text","label":"What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Estimate amount of expenses incurred for arrangement of the insured event.","options":[],"required":null,"pdf_field":""},{"help":"Include description of equipment or insured property","type":"text","label":"Details of the property damaged.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of damages to the property.","options":[],"required":null,"pdf_field":""},{"help":"Explain cause of damage","type":"text","label":"How were damages to such property caused.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether the property was in use at the time of loss.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether the property was stored or in use at the time of loss.","options":["Stored","In use"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Location of the property at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether the property was owned or rented.","options":["Owned","Rented"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"If the property was owned then please specify whether the property purchased was new or second hand.","options":["New","Second hand"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of the damages caused to the property.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether damage to the property is total loss or can be repaired.","options":["Total loss","Repairable"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If repairable then the name and address of repairer.","options":[],"required":null,"pdf_field":""},{"help":"Use format DD/MM/YYYY and time in HH:MM AM/PM","type":"date","label":"Date and time of damages to the insured property.","options":[],"required":null,"pdf_field":""},{"help":"If loss reported to police","type":"text","label":"Name and address of police station where such loss has been reported.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Damages to Tapes and Negatives","fields":[{"help":"Use format DD/MM/YYYY and time in HH:MM AM/PM","type":"date","label":"Date and time of damages to tapes/ negatives.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Location of loss","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give details of the nature and the cause of loss.","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Approx. amount of expenses incurred in making such tape/ negative.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give details of such damages","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether the damages to tapes/ negative are repairable.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If repairable","type":"text","label":"If yes then place where the repairs would take place.","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Approx expenses incurred for the repairs.","options":[],"required":null,"pdf_field":""},{"help":"Use format DD/MM/YYYY","type":"date","label":"Date of completion of shooting / event for which the tapes / negatives have been lost.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Whether any attempt has been done to minimize the losses.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Third Party Liability Details","fields":[{"help":"","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Approx amount of liability.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State where such person were at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Has the accident caused damage to Property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give name/es, address/es Occupation/s of such person/s","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Compromise Details","fields":[{"help":"","type":"choice","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":"","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":"","type":"text","label":"What is the present status of compromise / settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What are the circumstances /Evidence that favour a Compromise?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other circumstance/evidence.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Has any person made any claim upon you?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use format DD/MM/YYYY and time in HH:MM AM/PM","type":"date","label":"Date and time when you were intimated of such claim.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"","type":"choice","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":"Provide next hearing date if applicable","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":"","type":"choice","label":"Have any notices / summons of the court been received","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copies if yes","type":"choice","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 all relevant court 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":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Personal Accident","fields":[{"help":"","type":"text","label":"Name and address of the person who has been injured.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of injury / death","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Details of the accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Was such person a legal audience or was an employee.","options":["Legal audience","Employee"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Where were such persons at the time of injury.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether reported to Police.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If reported to police","type":"text","label":"If yes then name and address of Police Station.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give details of the incident leading to such injury.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Were any attempts made to avoid such accident. If yes, then give details.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other information necessary for the processing of the claim.","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital details if applicable","type":"text","label":"Was the injured / deceased person moved to hospital immediately after the accident? If yes, Name & address of the hospital","options":[],"required":null,"pdf_field":""},{"help":"Provide details of disability if any","type":"text","label":"Has the accident resulted into loss of hand/s or foot/feet or eye/s or permanent disability of any other type which may prevent the insured from engaging in or being occupied with or giving attention to any employment or occupation whatsoever? If yes, please give details","options":[],"required":null,"pdf_field":""},{"help":"Use format DD/MM/YYYY and time in HH:MM AM/PM","type":"date","label":"Date & time of injury / death","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Electronic Fund Transfer (EFT) Mandate","fields":[{"help":"","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"Payee Name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"Payee Account No.","options":[],"required":null,"pdf_field":""},{"help":"If Others, specify type","type":"choice","label":"Type of Account","options":["Savings","Current","Others (specify)"],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"Name of the Bank","options":[],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"Address of the Bank","options":[],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"If opting for EFT","type":"text","label":"Permanent Account Number (PAN) of Payee:","options":[],"required":null,"pdf_field":""},{"help":"Mandatory for EFT","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the Payee.","options":[],"required":true,"pdf_field":""},{"help":"Mandatory for EFT","type":"attachment","label":"Please attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Signature","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Event Insurance (Commercial)","attachments":["Copies of other insurance policies if applicable","Copy of notification and bill if claim has been made in writing","Copies of court orders and documents if court case is involved","Original Blank Cancelled Cheque signed by the Payee (for EFT)","PAN Card copy of Payee (for EFT)"],"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 material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or suppression of material information will void the policy and claims.","Receipt of this 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 for KYC."],"dropped_labels":3},"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/2234-claim-form-for-event-insurance"}