{"id":2242,"title":"ICICI LOMBARD HEALTH CARE CLAIM FORM - TRIPSECURE PLUS","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/tripsecure-plus-claim-forms-final.pdf","sha256":"1cc18b0325351138f4a084cfc2cb698eca04957201ced85ac5d268138b37860b","pages":16,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured or claimant to file a domestic travel insurance claim under the TripSecure Plus policy with ICICI Lombard. The insured or claimant fills it to provide details of the claim and submit supporting documents.","notes":["Use original bills and receipts; photocopies may delay claim processing.","Provide mobile number and email ID to receive claim status updates.","Every claim must be accompanied by original ticket/boarding pass or passport copy showing travel dates.","Fill all questions completely; attach additional sheets if space is insufficient.","Deductible amount as per policy schedule must be borne by the insured.","Doctor's report is mandatory for accident and medical claims.","Provide bank details and documents for electronic fund transfer (NEFT) as per IRDA guidelines.","Submission of documents or bank details does not imply admission of liability.","RTGS/NEFT terms and conditions apply for claim payments via electronic transfer."],"title":"ICICI LOMBARD HEALTH CARE CLAIM FORM - TRIPSECURE PLUS","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016"},"purpose":"claim","sections":[{"title":"Documents Submitted","fields":[{"help":"Indicate if the claim form is submitted","type":"checkbox","label":"Claim Form","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if the policy certificate is submitted","type":"checkbox","label":"Policy Certificate","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if ticket or boarding pass is submitted","type":"checkbox","label":"Ticket/Boarding pass issued by service provider","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if incident letter is submitted","type":"checkbox","label":"Incident letter","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if ID proof copy is submitted","type":"checkbox","label":"Copy of ID proof","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if cancelled cheque is submitted","type":"checkbox","label":"Cancelled cheque (in case NEFT form not attested by bank)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if declaration letter is submitted","type":"checkbox","label":"Declaration letter (in case if claim being settled into account other than Insureds)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Policy Details","fields":[{"help":"Enter your policy number","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter policy start date","type":"date","label":"Policy Start Date","options":[],"required":true,"pdf_field":""},{"help":"Enter policy end date","type":"date","label":"Policy End Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Insured Details","fields":[{"help":"Enter full name of insured","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Sex","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter current address","type":"text","label":"Current Address","options":[],"required":true,"pdf_field":""},{"help":"Enter address in country of residence","type":"text","label":"Address in Country of Residence","options":[],"required":false,"pdf_field":""},{"help":"Enter overseas phone number","type":"phone","label":"Phone No. Overseas","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number in India with STD code","type":"phone","label":"Phone No. India (With STD Code)","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter claim reference number if any","type":"text","label":"Claims Ref No. (As provided)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Claimant Details","fields":[{"help":"Enter full name of claimant","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Sex","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Specify relationship to policyholder","type":"text","label":"Relationship with the Policyholder","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's address","type":"text","label":"Claimant's Address","options":[],"required":true,"pdf_field":""},{"help":"Enter office phone number","type":"phone","label":"Phone No. (Off)","options":[],"required":false,"pdf_field":""},{"help":"Enter residential phone number","type":"phone","label":"Phone No. (Res)","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"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":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration / Authorisation","fields":[{"help":"Sign here","type":"signature","label":"Insured's Signature","options":[],"required":true,"pdf_field":""},{"help":"Sign here if claimant is different","type":"signature","label":"Claimant or authorized person Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Annexure I - Domestic Personal Accident Cover","fields":[{"help":"Describe accident details","type":"text","label":"Please state circumstances of accident i.e. how, when, where it took place","options":[],"required":true,"pdf_field":""},{"help":"Describe injury","type":"text","label":"Nature of Injury","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment / surgery under taken","options":[],"required":true,"pdf_field":""},{"help":"Provide hospital/clinic contact details","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic","options":[],"required":true,"pdf_field":""},{"help":"Provide doctor’s name and qualifications","type":"text","label":"Treating Doctor’s Name & Qualifications","options":[],"required":true,"pdf_field":""},{"help":"Provide office and mobile numbers","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":true,"pdf_field":""},{"help":"Provide room/ward/bed number if applicable","type":"text","label":"Room /Ward / Bed Number","options":[],"required":false,"pdf_field":""},{"help":"Provide treatment start and end dates","type":"date","label":"Dates of treatment From / To","options":[],"required":true,"pdf_field":""},{"help":"Date doctor was contacted","type":"date","label":"Attending Doctor’s Report - Date doctor contacted","options":[],"required":true,"pdf_field":""},{"help":"Describe ailment","type":"text","label":"Nature of Ailment","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided","options":[],"required":true,"pdf_field":""},{"help":"Mention other diseases if any","type":"text","label":"Describe any other disease or infirmity affecting present condition","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Was the accident due to Pregnancy","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Was the accident due to any pre-existing condition","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if pre-existing condition applies","type":"text","label":"If yes, please give details","options":[],"required":false,"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":true,"pdf_field":""},{"help":"Tick applicable loss type","type":"choice","label":"Loss Incurred (Please tick)","options":["Death","Permanent Total Disability","Permanent Partial Disability"],"required":true,"pdf_field":""},{"help":"Provide details if 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taken","options":[],"required":true,"pdf_field":""},{"help":"Provide hospital/clinic contact details","type":"text","label":"Provide name, address & telephone number of Hospital / Clinic","options":[],"required":true,"pdf_field":""},{"help":"Provide doctor’s name and qualifications","type":"text","label":"Treating Doctor’s Name & Qualifications","options":[],"required":true,"pdf_field":""},{"help":"Provide office and mobile numbers","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":true,"pdf_field":""},{"help":"Provide room/ward/bed number if applicable","type":"text","label":"Room /Ward / Bed Number","options":[],"required":false,"pdf_field":""},{"help":"Provide treatment start and end dates","type":"date","label":"Dates of treatment From / To","options":[],"required":true,"pdf_field":""},{"help":"Date doctor was contacted","type":"date","label":"Attending Doctor’s Report - Date doctor contacted","options":[],"required":true,"pdf_field":""},{"help":"Describe ailment","type":"text","label":"Nature of Ailment","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided","options":[],"required":true,"pdf_field":""},{"help":"Mention other diseases if any","type":"text","label":"Describe any other disease or infirmity affecting present condition","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Was the accident due to Pregnancy","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Was the accident due to any pre-existing condition","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if pre-existing condition applies","type":"text","label":"If yes, please give details","options":[],"required":false,"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":true,"pdf_field":""},{"help":"Tick applicable loss type","type":"choice","label":"Loss Incurred (Please tick)","options":["Death","Permanent Total Disability","Permanent Partial Disability"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Permanent Total Disability (Details)","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Permanent Partial Disability (Details)","options":[],"required":false,"pdf_field":""},{"help":"Doctor to sign and date","type":"signature","label":"Medical Doctor’s Signature and Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant and treating doctor"},{"title":"Annexure III - Accidental Hospitalization Expenses","fields":[{"help":"List details of medical treatment, date, and expenses in foreign currency or INR","type":"table","label":"Medical Treatment Expenses Details","options":[],"required":true,"pdf_field":""},{"help":"Date doctor was contacted","type":"date","label":"Attending Doctor’s Report - Date doctor contacted","options":[],"required":true,"pdf_field":""},{"help":"Describe ailment","type":"text","label":"Nature of Ailment","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided","options":[],"required":true,"pdf_field":""},{"help":"Date symptoms first appeared","type":"date","label":"When did patient’s symptoms first appear?","options":[],"required":true,"pdf_field":""},{"help":"Mention other diseases if any","type":"text","label":"Describe any other disease or infirmity affecting present condition","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Was the ailment due to Pregnancy","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if pre-existing condition applies","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Provide hospital/clinic contact details","type":"text","label":"Provide Name, address & telephone number of Hospital / Clinic","options":[],"required":true,"pdf_field":""},{"help":"Provide doctor’s name and qualifications","type":"text","label":"Treating Doctor’s Name & Qualification","options":[],"required":true,"pdf_field":""},{"help":"Provide office and mobile numbers","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":true,"pdf_field":""},{"help":"Provide room/ward/bed number if applicable","type":"text","label":"Room / Ward / Bed Number","options":[],"required":false,"pdf_field":""},{"help":"Provide treatment start and end dates","type":"date","label":"Date of Treatment From / To","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant and treating doctor"},{"title":"Annexure IV - En-Route Accidental Hospitalization Expenses - Common Carrier","fields":[{"help":"Date doctor was contacted","type":"date","label":"Attending Doctor’s Report - Date doctor contacted","options":[],"required":true,"pdf_field":""},{"help":"Time doctor was contacted (HH:MM)","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"Describe ailment","type":"text","label":"Nature of Ailment","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided","options":[],"required":true,"pdf_field":""},{"help":"Date symptoms first appeared","type":"date","label":"When did patient’s symptoms first appear?","options":[],"required":true,"pdf_field":""},{"help":"Mention other diseases if any","type":"text","label":"Describe any other disease or infirmity affecting present condition","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Was the ailment due to Pregnancy","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if pre-existing condition applies","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Provide hospital/clinic contact details","type":"text","label":"Provide Name, address & telephone number of Hospital / Clinic","options":[],"required":true,"pdf_field":""},{"help":"Provide doctor’s name and qualifications","type":"text","label":"Treating Doctor’s Name & Qualification","options":[],"required":true,"pdf_field":""},{"help":"Provide office and mobile numbers","type":"phone","label":"Treating Doctor’s Telephone Number (O) (M)","options":[],"required":true,"pdf_field":""},{"help":"Provide room/ward/bed number if applicable","type":"text","label":"Room / Ward / Bed Number","options":[],"required":false,"pdf_field":""},{"help":"Provide treatment start and end dates","type":"date","label":"Date of Treatment From / To","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant and treating doctor"},{"title":"Annexure V - Domestic OPD Expenses","fields":[{"help":"Describe incident details","type":"text","label":"Incident details","options":[],"required":true,"pdf_field":""},{"help":"Enter treatment dates","type":"date","label":"Dates of Treatment From / To","options":[],"required":true,"pdf_field":""},{"help":"Enter symptom onset date","type":"date","label":"Date of onset of Symptoms","options":[],"required":true,"pdf_field":""},{"help":"Enter healthcare provider name","type":"text","label":"Provider Name","options":[],"required":true,"pdf_field":""},{"help":"Enter provider address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter provider contact number","type":"phone","label":"Contact No.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure VI - En-Route OPD Expenses - Common Carrier","fields":[{"help":"Describe incident details","type":"text","label":"Incident details","options":[],"required":true,"pdf_field":""},{"help":"Enter treatment dates","type":"date","label":"Dates of Treatment From / To","options":[],"required":true,"pdf_field":""},{"help":"Enter symptom onset date","type":"date","label":"Date of onset of Symptoms","options":[],"required":true,"pdf_field":""},{"help":"Enter healthcare provider name","type":"text","label":"Provider Name","options":[],"required":true,"pdf_field":""},{"help":"Enter provider address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter provider contact number","type":"phone","label":"Contact No.","options":[],"required":true,"pdf_field":""},{"help":"Select mode of travel","type":"choice","label":"Mode of Travel (as selected in Policy Schedule)","options":["All modes","Flight","Train/Cab/Taxi/Water Transport"],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure VII - Domestic Loss of Baggage & Personal Effects","fields":[{"help":"Enter date of loss","type":"date","label":"Date of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe loss incident","type":"text","label":"Incident Details (Please state how, when, and where the loss occurred. Mention theft / burglary / larceny / robbery / mugging details.)","options":[],"required":true,"pdf_field":""},{"help":"Enter place of loss","type":"text","label":"Place of Loss","options":[],"required":true,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Were the authorities notified?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide authority name if notified","type":"text","label":"If Yes, mention name of authority (police / hotel / accommodation / service provider)","options":[],"required":false,"pdf_field":""},{"help":"List lost items; attach sheet if needed","type":"text","label":"List of Items Lost","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated value","type":"amount","label":"Estimated Value of Items","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Claimant’s/Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure VIII - Theft / Burglary of Home Contents","fields":[{"help":"Enter property address","type":"text","label":"Address of property where loss was sustained","options":[],"required":true,"pdf_field":""},{"help":"Enter date of loss","type":"date","label":"Date of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe incident details","type":"text","label":"Cause of Loss (Incident details) (Please describe how, when and where the theft/burglary took place. Include details of any forced entry.)","options":[],"required":true,"pdf_field":""},{"help":"Describe nature and circumstances of loss","type":"text","label":"Exact description of nature of loss and circumstances","options":[],"required":true,"pdf_field":""},{"help":"List items lost or damaged; attach sheet if needed","type":"text","label":"Items lost or damaged","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Claimant’s/Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure IX - Missed Connection","fields":[{"help":"Describe reason for missed connection","type":"text","label":"Contingency / Reason for Missed Connection","options":[],"required":true,"pdf_field":""},{"help":"Provide prior segment transport details","type":"text","label":"Transport Details – Prior Segment (Flight / Train)","options":[],"required":true,"pdf_field":""},{"help":"Select transport type","type":"choice","label":"Type of Transport","options":["Flight","Train"],"required":true,"pdf_field":""},{"help":"Enter carrier name","type":"text","label":"Name of Carrier","options":[],"required":true,"pdf_field":""},{"help":"Enter flight or train number","type":"text","label":"Transport Number (Flight No. / Train No.)","options":[],"required":true,"pdf_field":""},{"help":"Enter scheduled arrival time (HH:MM)","type":"text","label":"Scheduled Arrival Time","options":[],"required":true,"pdf_field":""},{"help":"Enter actual arrival time (HH:MM)","type":"text","label":"Actual Arrival Time","options":[],"required":true,"pdf_field":""},{"help":"Select reason for delay","type":"choice","label":"Reason for Delay of the Previous Flight / Train","options":["Inclement Weather","Strike / Job Action","Equipment Failure","Technical Instructions / Operational Hold","Act of Terrorism","Other"],"required":true,"pdf_field":""},{"help":"Provide missed segment details","type":"text","label":"Connection Details – Missed Segment (Flight / Train)","options":[],"required":true,"pdf_field":""},{"help":"Select connecting transport type","type":"choice","label":"Type of Connecting Transport","options":["Flight","Train"],"required":true,"pdf_field":""},{"help":"Enter connecting carrier name","type":"text","label":"Connecting Carrier Name","options":[],"required":true,"pdf_field":""},{"help":"Enter connecting flight or train number","type":"text","label":"Connecting Transport Number (Flight No. / Train No.)","options":[],"required":true,"pdf_field":""},{"help":"Enter scheduled departure time (HH:MM)","type":"text","label":"Scheduled Departure Time (Missed Segment)","options":[],"required":true,"pdf_field":""},{"help":"Enter cancellation or no show charges retained","type":"amount","label":"Expenses Due to Missed Connection - Cancellation / No Show Charges Retained","options":[],"required":true,"pdf_field":""},{"help":"Indicate if refund/no show document is attached","type":"yes-no","label":"Refund / No Show Documentation from Carrier Attached?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if supporting bills/receipts are attached","type":"yes-no","label":"Supporting Bills / Receipts Attached?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter additional fare amount","type":"amount","label":"Additional Fare for Alternate Travel Arrangement","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Claimant’s/Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure X - Domestic Trip Cancellation and Interruption","fields":[{"help":"Select applicable option","type":"choice","label":"Trip Cancelled / Trip Interrupted / Also claiming for Trip Regained","options":["Trip Cancelled","Trip Interrupted","Trip Regained"],"required":true,"pdf_field":""},{"help":"Describe reason for cancellation or interruption","type":"text","label":"Reason for Trip Cancellation / Interruption","options":[],"required":true,"pdf_field":""},{"help":"Enter date of cancellation or interruption","type":"date","label":"Trip Cancellation / Interruption date","options":[],"required":true,"pdf_field":""},{"help":"Enter original travel dates","type":"date","label":"Original Travel Dates From / To","options":[],"required":true,"pdf_field":""},{"help":"If not insured, provide person details","type":"text","label":"Person Affected and Relationship with the Insured","options":[],"required":false,"pdf_field":""},{"help":"List losses or expenses with amounts","type":"table","label":"Details of Losses / Expenses Incurred","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure XI - Domestic Loss of Checked In Baggage","fields":[{"help":"Describe loss or delay details","type":"text","label":"Describe when & where the Loss / Delay took place","options":[],"required":true,"pdf_field":""},{"help":"Enter delay duration in hours","type":"number","label":"State the extent of Delay / Loss (In hrs)","options":[],"required":true,"pdf_field":""},{"help":"Enter place of delay or loss","type":"text","label":"Place of Delay / Loss","options":[],"required":true,"pdf_field":""},{"help":"Enter carrier name","type":"text","label":"Name the common carrier","options":[],"required":true,"pdf_field":""},{"help":"Enter number of hours bag was delayed","type":"number","label":"No. of Hours of bag delay","options":[],"required":true,"pdf_field":""},{"help":"Enter actual arrival date and time","type":"text","label":"Actual Date & Time of Arrival of flight at Port","options":[],"required":true,"pdf_field":""},{"help":"Enter actual delivery date and time","type":"text","label":"Actual Date & Time when Bags were delivered","options":[],"required":true,"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":true,"pdf_field":""},{"help":"Enter PIR number","type":"text","label":"Property Irregularity Report (PIR) number from Airline/Common Carrier","options":[],"required":true,"pdf_field":""},{"help":"Provide compensation details","type":"text","label":"Details of compensation required from carrier","options":[],"required":false,"pdf_field":""},{"help":"List items, purchase dates, and costs","type":"table","label":"Details of items purchased / lost / expenses","options":[],"required":true,"pdf_field":""},{"help":"Enter compensation amount received","type":"amount","label":"Compensation From Airlines","options":[],"required":false,"pdf_field":""},{"help":"Enter net claim amount","type":"amount","label":"Net Amount","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure XII - Domestic Delay of Checked In Baggage","fields":[{"help":"Describe loss or delay details","type":"text","label":"Describe when & where the Loss / Delay took place","options":[],"required":true,"pdf_field":""},{"help":"Enter delay duration in hours","type":"number","label":"State the extent of Delay / Loss (In hrs)","options":[],"required":true,"pdf_field":""},{"help":"Enter place of delay or loss","type":"text","label":"Place of Delay / Loss","options":[],"required":true,"pdf_field":""},{"help":"Enter carrier name","type":"text","label":"Name the common carrier","options":[],"required":true,"pdf_field":""},{"help":"Enter number of hours bag was delayed","type":"number","label":"No. of Hours of bag delay","options":[],"required":true,"pdf_field":""},{"help":"Enter actual arrival date and time","type":"text","label":"Actual Date & Time of Arrival of flight at Port","options":[],"required":true,"pdf_field":""},{"help":"Enter actual delivery date and time","type":"text","label":"Actual Date & Time when Bags were delivered","options":[],"required":true,"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":true,"pdf_field":""},{"help":"Enter PIR number","type":"text","label":"Property Irregularity Report (PIR) number from Airline/Common Carrier","options":[],"required":true,"pdf_field":""},{"help":"Provide compensation details","type":"text","label":"Details of compensation required from carrier","options":[],"required":false,"pdf_field":""},{"help":"List items, purchase dates, and costs","type":"table","label":"Details of items purchased / lost / expenses","options":[],"required":true,"pdf_field":""},{"help":"Enter compensation amount received","type":"amount","label":"Compensation From Airlines","options":[],"required":false,"pdf_field":""},{"help":"Enter net claim amount","type":"amount","label":"Net Amount","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure XIII - Domestic Flight Delay – Fixed Benefit","fields":[{"help":"Enter flight number","type":"text","label":"Flight Number","options":[],"required":true,"pdf_field":""},{"help":"Enter airline name","type":"text","label":"Airline Name","options":[],"required":true,"pdf_field":""},{"help":"Enter scheduled departure date and time","type":"text","label":"Scheduled Date & Time of Departure","options":[],"required":true,"pdf_field":""},{"help":"Enter actual delayed departure date and time","type":"text","label":"Actual Date & Time of Departure (Delayed)","options":[],"required":true,"pdf_field":""},{"help":"Enter total delay duration","type":"text","label":"Total Delay (minutes / hours)","options":[],"required":true,"pdf_field":""},{"help":"Describe how, when and where the delay occurred","type":"text","label":"Incident Details (Narrative)","options":[],"required":true,"pdf_field":""},{"help":"Select reason for delay","type":"choice","label":"Delay Reason (as confirmed by airline)","options":["Operational delay","Weather","Technical reason","Crew / staff unavailability","Other"],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Claimant’s/Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Annexure XIV - Domestic Airline-Operated Cancellation Benefit","fields":[{"help":"Describe flight cancellation details","type":"text","label":"Incident Details (Please describe how, when and where the flight cancellation occurred.)","options":[],"required":true,"pdf_field":""},{"help":"Enter airline name","type":"text","label":"Airline Name","options":[],"required":true,"pdf_field":""},{"help":"Enter flight number","type":"text","label":"Flight Number","options":[],"required":true,"pdf_field":""},{"help":"Enter PNR number","type":"text","label":"PNR Number","options":[],"required":true,"pdf_field":""},{"help":"Enter scheduled departure date and time","type":"text","label":"Flight Details - Scheduled Date & Time of Departure","options":[],"required":true,"pdf_field":""},{"help":"Enter cancellation date and time","type":"text","label":"Cancellation Date & Time (as confirmed by airline)","options":[],"required":true,"pdf_field":""},{"help":"Select reason for cancellation","type":"choice","label":"Reason for Cancellation (as per airline communication)","options":["Operational","Weather","Technical","Crew/Staff Scheduling","Other"],"required":true,"pdf_field":""},{"help":"Indicate if refund/no show document is attached","type":"yes-no","label":"Refund / No Show Document Attached","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter amount refunded or forfeited","type":"amount","label":"Amount Refunded / Forfeited","options":[],"required":false,"pdf_field":""},{"help":"Enter rebooked flight number if applicable","type":"text","label":"If Yes, Rebooked Flight Number","options":[],"required":false,"pdf_field":""},{"help":"Indicate if re-accommodation was provided","type":"yes-no","label":"Was the customer re accommodated by the airline on another flight?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter rebooked departure date and time","type":"text","label":"Rebooked Departure Date & Time","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Claimant’s/Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"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 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","type":"text","label":"PAN no. of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer/policy holder"}],"deadlines":[""],"applies_to":"Domestic travel insurance claims under the TripSecure Plus policy","attachments":["Completely filled and signed claim form","Supporting claim documents as per Letter of Requirement (LOR)","Original ticket/boarding pass or copy of passport indicating travel dates","Original bills and receipts for expenses claimed","Medical reports, discharge summaries, and doctor's reports as applicable","Police reports, FIR, Panchnama, Property Irregularity Report (PIR) as applicable","Refund vouchers/details from service provider for cancellation/compensation","Declaration letter if claim is settled into account other than insured's","Self-attested ID proof of proposer/policy holder","Cancelled cheque or bank attested passbook copy with IFSC code","NEFT details and KYC number"],"declarations":["The information provided in the claim form is true, correct and complete.","All persons having interest in the property are disclosed as per the proposal or policy endorsements.","No material information relevant to claim processing is withheld or undisclosed.","False or fraudulent statements or concealment of material information voids the policy and claim rights.","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.","Non-submission of original bills and receipts may delay claim settlement.","The insured authorizes release of medical and claim information to ICICI Lombard and its representatives.","The authorization is valid for the duration of the claim and a copy can be requested.","Filing a fraudulent claim may lead to prosecution for insurance fraud."],"dropped_labels":10},"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/2242-icici-lombard-health-care-claim-form-tripsecure-plus"}