{"id":2235,"title":"ICICI Lombard Health Care Claim Form - Domestic Travel","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-domestic8c0007ff45fd68ff8a0df0055fa74c36.pdf","sha256":"a607239497c4f2bd00f04ee771bbd06570f5ca44a0004eef6cc9b1071e123a03","pages":17,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured or claimant to file a claim under the Ride Safe Travel Insurance policy for various travel-related coverages. The insured or claimant fills the form.","notes":["Use original bills and receipts; non-submission of originals delays claim settlement.","Provide mobile number and email ID to receive claim status updates.","Every claim must be accompanied by original ticket/boarding pass or passport copy indicating travel dates.","Fill all dates in DD-MM-YYYY format and use block letters where applicable.","For claimed amount over ₹100,000, KYC details are mandatory as per IRDA guidelines.","All claim settlements should be made through NEFT; provide bank account details with cancelled cheque or bank attested passbook copy.","Attach certified copies of identity and address proofs as required in KYC.","If insufficient space, attach additional sheets.","Submission of documents or bank details does not imply admission of liability.","For electronic fund transfer, provide accurate bank details; ICICI Lombard is not responsible for errors in details provided.","RTGS/NEFT facility activation may take up to 15 days after receipt of mandate form.","Proposer/policy holder may terminate RTGS/NEFT facility with 15 days prior written notice.","Claims may require additional documents as deemed fit by the company."],"title":"ICICI Lombard Health Care Claim Form - Domestic Travel","submit":{"to":"ICICI Lombard Healthcare, ICICI Bank tower, Plot No 12, Financial district, Nanakramguda, Gachibowli, Hyderabad, Telangana - 500 032","how":"post","address":"ICICI Lombard Healthcare, ICICI Bank tower, Plot No 12, Financial district, Nanakramguda, Gachibowli, Hyderabad, Telangana - 500 032"},"purpose":"claim","sections":[{"title":"Part A - Policy and Insured Details","fields":[{"help":"Enter your insurance policy number.","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy start date.","type":"date","label":"Policy Start Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy end date.","type":"date","label":"Policy End Date","options":[],"required":null,"pdf_field":""},{"help":"Select the gender of the insured.","type":"choice","label":"Sex","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter current address of the insured.","type":"text","label":"Current Address","options":[],"required":null,"pdf_field":""},{"help":"Enter address in country of residence if different.","type":"text","label":"Address in Country of Residence","options":[],"required":null,"pdf_field":""},{"help":"Enter overseas phone number with STD code if applicable.","type":"phone","label":"Phone No. Overseas","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number in India with STD code.","type":"phone","label":"Phone No. India","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number.","type":"phone","label":"Mobile No","options":[],"required":null,"pdf_field":""},{"help":"Enter email address.","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter passport number.","type":"text","label":"Passport No.","options":[],"required":null,"pdf_field":""},{"help":"Enter claim reference number if available.","type":"text","label":"Claims Ref No. (As provided)","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant/Nominee"},{"title":"Part A - Claimant Details","fields":[{"help":"Enter full name of claimant.","type":"text","label":"Full Name","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's date of birth.","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select claimant's gender.","type":"choice","label":"Sex","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Specify relationship to policyholder.","type":"text","label":"Relationship with the Policyholder","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's address.","type":"text","label":"Claimant's Address","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's email address.","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Select your capacity for claim.","type":"choice","label":"In what capacity are you making this claim?","options":["Self","Nominee","Insured’s Relative"],"required":null,"pdf_field":""}],"filled_by":"Claimant (if different from insured)"},{"title":"Declaration / Authorization","fields":[{"help":"Enter date of signing.","type":"date","label":"Dated","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign here as insured.","type":"signature","label":"Insured's Signature","options":[],"required":true,"pdf_field":""},{"help":"Sign here if claimant or authorized person.","type":"signature","label":"Claimant or authorized person Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured or claimant"},{"title":"Annexure I - Hospitalization Expenses for Injury","fields":[{"help":"Provide date/time doctor contacted, nature of ailment, diagnosis, treatment details, symptom onset, other diseases, pregnancy status, pre-existing conditions, and doctor’s signature.","type":"text","label":"Attending Doctor’s Report","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital/clinic contact details.","type":"text","label":"Name, address & telephone number of Hospital / Clinic","options":[],"required":null,"pdf_field":""},{"help":"Provide treating doctor’s name and qualification.","type":"text","label":"Treating Doctor’s Name & Qualification","options":[],"required":null,"pdf_field":""},{"help":"Provide office and mobile phone numbers of treating doctor.","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":null,"pdf_field":""},{"help":"Provide room/ward/bed number.","type":"text","label":"Room / Ward / Bed Number","options":[],"required":null,"pdf_field":""},{"help":"Provide treatment start and end dates.","type":"date","label":"Date of Treatment From - To","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure II - Repatriation of Remains","fields":[{"help":"Describe cause and circumstances of death.","type":"text","label":"Cause / Circumstances of death","options":[],"required":null,"pdf_field":""},{"help":"Enter date of death.","type":"date","label":"Date of death of insured","options":[],"required":null,"pdf_field":""},{"help":"Provide details of repatriation or funeral expenses.","type":"text","label":"Details of expenses incurred for repatriation of Remains / Funeral","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure III - Checked-in Baggage Loss / Delay","fields":[{"help":"Describe details of baggage loss or delay.","type":"text","label":"Describe when & where the Loss / Delay took place","options":[],"required":null,"pdf_field":""},{"help":"Enter duration of delay in hours.","type":"number","label":"State the extent of Delay / Loss (In hrs)","options":[],"required":null,"pdf_field":""},{"help":"Enter place where baggage was lost or delayed.","type":"text","label":"Place of Delay / Loss","options":[],"required":null,"pdf_field":""},{"help":"Enter name of airline or carrier.","type":"text","label":"Name the common carrier","options":[],"required":null,"pdf_field":""},{"help":"Enter number of hours baggage was delayed.","type":"number","label":"No. of Hours of bag delay","options":[],"required":null,"pdf_field":""},{"help":"Enter actual arrival date and time of flight.","type":"date","label":"Actual Date & Time of Arrival of flight at Port","options":[],"required":null,"pdf_field":""},{"help":"Enter date and time baggage was delivered.","type":"date","label":"Actual Date & Time when Bags were delivered","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no.","type":"yes-no","label":"Had the common carrier been notified at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter PIR number issued by airline.","type":"text","label":"Property Irregularity Report (PIR) number from Airline/Common Carrier","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure IV - Personal Accident","fields":[{"help":"Describe accident details.","type":"text","label":"Please state circumstances of accident i.e. how, when, where it took place","options":[],"required":null,"pdf_field":""},{"help":"Describe injury nature.","type":"text","label":"Nature of Injury","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis and treatment details.","type":"text","label":"State diagnosis and nature of treatment / surgery undertaken","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital/clinic contact details.","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic","options":[],"required":null,"pdf_field":""},{"help":"Provide treating doctor’s name and qualifications.","type":"text","label":"Treating Doctor’s Name & Qualifications","options":[],"required":null,"pdf_field":""},{"help":"Provide office and mobile phone numbers of doctor.","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":null,"pdf_field":""},{"help":"Provide room/ward/bed number.","type":"text","label":"Room / Ward / Bed Number","options":[],"required":null,"pdf_field":""},{"help":"Provide treatment start and end dates.","type":"date","label":"Dates of treatment From - To","options":[],"required":null,"pdf_field":""},{"help":"Provide date/time doctor contacted, nature of ailment, diagnosis, treatment details, pregnancy and pre-existing condition status, and doctor’s signature.","type":"text","label":"Attending Doctor’s Report","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no.","type":"yes-no","label":"Was the accident due to Pregnancy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick yes or no and provide details if yes.","type":"yes-no","label":"Was the accident due to any pre-existing condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick yes or no.","type":"yes-no","label":"Can the patient be evacuated back to the Republic of India?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure V - Trip Cancellation and Interruption","fields":[{"help":"Tick applicable option.","type":"choice","label":"Trip Cancelled / Trip Interrupted / Also claiming for Trip Regained","options":["Trip Cancelled","Trip Interrupted","Trip Regained"],"required":null,"pdf_field":""},{"help":"Describe reason for cancellation or interruption.","type":"text","label":"Reason for Trip Cancellation / Interruption","options":[],"required":null,"pdf_field":""},{"help":"Enter date of cancellation or interruption.","type":"date","label":"Trip Cancellation / Interruption date","options":[],"required":null,"pdf_field":""},{"help":"Enter original travel start and end dates.","type":"date","label":"Original Travel Dates From - To","options":[],"required":null,"pdf_field":""},{"help":"Provide name and relationship of affected person if not insured.","type":"text","label":"Person Affected and Relationship with the Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure VI - Trip Delay","fields":[{"help":"Describe reason for trip delay.","type":"text","label":"Reason for Trip Delay","options":[],"required":null,"pdf_field":""},{"help":"Enter original travel dates.","type":"date","label":"Original Travel Dates From - To","options":[],"required":null,"pdf_field":""},{"help":"Enter date of trip delay.","type":"date","label":"Trip delayed on","options":[],"required":null,"pdf_field":""},{"help":"Provide name and relationship if not insured.","type":"text","label":"Person Affected and Relationship with the Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure VII - Missed (Flight) Connection","fields":[{"help":"Provide flight details causing missed connection.","type":"text","label":"Which flight was delayed causing a missed connection?","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for flight delay.","type":"text","label":"Reason for delay of the flight","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure VIII - Compassionate Visit","fields":[{"help":"Tick applicable option.","type":"choice","label":"Person Hospitalised (Insured / Family Member)","options":["Insured","Family Member"],"required":null,"pdf_field":""},{"help":"Provide name if different from insured.","type":"text","label":"Name of the person hospitalized (if not insured)","options":[],"required":null,"pdf_field":""},{"help":"Provide relationship to insured.","type":"text","label":"Relationship with the insured","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital/clinic contact details.","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic","options":[],"required":null,"pdf_field":""},{"help":"Provide treating doctor’s name and qualifications.","type":"text","label":"Treating Doctor’s Name & Qualifications","options":[],"required":null,"pdf_field":""},{"help":"Provide office and mobile phone numbers of doctor.","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":null,"pdf_field":""},{"help":"Provide room/ward/bed number.","type":"text","label":"Room / Ward / Bed Number","options":[],"required":null,"pdf_field":""},{"help":"Provide hospitalization start and end dates.","type":"date","label":"Dates of hospitalisation From - To","options":[],"required":null,"pdf_field":""},{"help":"Enter symptom onset date.","type":"date","label":"Date of onset of symptoms","options":[],"required":null,"pdf_field":""},{"help":"Provide date/time doctor contacted, diagnosis, treatment, pregnancy and pre-existing condition status, and doctor’s signature.","type":"text","label":"Attending Doctor’s Report","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated hospitalization duration.","type":"text","label":"Estimated time the patient would continue to be in the hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Annexure IX - Other Benefits","fields":[{"help":"Specify the benefit or loss claimed.","type":"text","label":"Benefit/loss for which claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured/Claimant"},{"title":"Part B - Fund Transfer NEFT Form","fields":[{"help":"Enter name as per bank records.","type":"text","label":"Proposer (policy holder)/ Employee name* (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number.","type":"text","label":"Proposer/ policy holder Bank account no.","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name.","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name.","type":"text","label":"Branch name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch address.","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code as per cheque leaf.","type":"text","label":"IFSC code no. of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of proposer.","type":"text","label":"PAN no. of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Sign here to authorize fund transfer.","type":"signature","label":"Account holder's Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter patient name.","type":"text","label":"Patient's Name (in respect of whom claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Enter policy number.","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter card or UHID number if applicable.","type":"text","label":"Card No./ UHID No.","options":[],"required":false,"pdf_field":""},{"help":"Enter group or company name if applicable.","type":"text","label":"Group/Company Name (for Group/Corporate policy holders)","options":[],"required":false,"pdf_field":""},{"help":"Enter claim number if available.","type":"text","label":"Claim Number (if allotted)","options":[],"required":false,"pdf_field":""},{"help":"Enter contact mobile number.","type":"phone","label":"Mobile/ Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address.","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured/Proposer/Policy holder"},{"title":"Part C – Know Your Customer (KYC)","fields":[{"help":"Select occupation type.","type":"choice","label":"Occupation Type","options":["Professional","Self Employed","Retired","Housewife","Student","Private Sector","Public Sector","Government Sector"],"required":true,"pdf_field":""},{"help":"Enter passport number if applicable.","type":"text","label":"Passport Number","options":[],"required":false,"pdf_field":""},{"help":"Enter voter ID number if applicable.","type":"text","label":"Voter ID Card","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN card number if applicable.","type":"text","label":"PAN Card","options":[],"required":false,"pdf_field":""},{"help":"Enter driving licence number if applicable.","type":"text","label":"Driving Licence","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhaar number if applicable.","type":"text","label":"UID (Aadhaar)","options":[],"required":false,"pdf_field":""},{"help":"Enter NREGA job card number if applicable.","type":"text","label":"NREGA Job Card","options":[],"required":false,"pdf_field":""},{"help":"Specify other ID document if applicable.","type":"text","label":"Others (any document notified by the central government)","options":[],"required":false,"pdf_field":""},{"help":"Enter full name as per ID proof.","type":"text","label":"Name (Same as ID proof)","options":[],"required":true,"pdf_field":""},{"help":"Enter maiden name if applicable.","type":"text","label":"Maiden Name (If any)","options":[],"required":false,"pdf_field":""},{"help":"Enter father or spouse name.","type":"text","label":"Father / Spouse Name","options":[],"required":true,"pdf_field":""},{"help":"Enter mother’s name.","type":"text","label":"Mother Name","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD-MM-YYYY format.","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender.","type":"choice","label":"Gender","options":["M- Male","F- Female","T- Transgender"],"required":true,"pdf_field":""},{"help":"Select marital status.","type":"choice","label":"Marital Status","options":["Married","Unmarried"],"required":true,"pdf_field":""},{"help":"Enter citizenship status.","type":"text","label":"Citizenship","options":[],"required":true,"pdf_field":""},{"help":"Enter country code of residence.","type":"text","label":"ISO 3166 Country Code of Jurisdiction of Residence","options":[],"required":true,"pdf_field":""},{"help":"Enter tax ID number if applicable.","type":"text","label":"Tax Identification Number or equivalent (If issued by jurisdiction)","options":[],"required":true,"pdf_field":""},{"help":"Enter place or city of birth.","type":"text","label":"Place / City of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select residential status.","type":"choice","label":"Residential Status","options":["Resident Individual","Foreign National","Non Resident Indian","Person of Indian Origin"],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression.","type":"signature","label":"Signature / Thumb Impression","options":[],"required":true,"pdf_field":""},{"help":"Attach recent passport size photo.","type":"photo","label":"Photo","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured/Proposer"}],"deadlines":[],"applies_to":"Domestic Travel Insurance claims under various coverages such as medical cover, repatriation, baggage loss/delay, personal accident, trip cancellation/interruption, trip delay, missed flight connection, compassionate visit, and others.","attachments":["Claim Form","Policy Certificate","Ticket/Boarding pass issued by service provider","Incident letter","Copy of ID proof","Cancelled cheque (in case NEFT form not attested by bank)","Declaration letter (in case if claim being settled into account other than Insureds)","Bills and receipt for additional expenses (food / stay/alternate travel arrangement)","Bills and receipt for medical expenses (hospital/investigations/medicines/consultation)","Communication from service provider (trip cancellation/delay , baggage loss/baggage delay)","Refund voucher/details from service provider for cancellation/compensation","PIR (property irregularity report) from service provider","Delivery receipts from service provider","Discharge summary and medical reports","Death certificate/ Post mortem report","FIR/Panchanma","Any other additional document as required by Insurer"],"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 the proposal or policy endorsement.","No material information relevant to claim processing is withheld or undisclosed.","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.","Authorization is given to ISM and ICICI Lombard to obtain and share information for claim investigation and recovery.","The company may call for additional documents for claim assessment.","Authorization is given to insurance companies, physicians, hospitals, or others to release information for claim processing.","ICICI Lombard or its representatives will use the information to evaluate and determine coverage.","A copy of this authorization can be requested and a photocopy is as valid as the original.","Authorization is valid for the duration of the claim and includes assistance service providers.","Filing a claim with false, incomplete or misleading information may lead to prosecution for insurance fraud."],"dropped_labels":16},"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/2235-icici-lombard-health-care-claim-form-domestic-travel"}