{"id":312,"title":"Claims Form- Director and Key Personnel Liability Insurance","purpose":"claim","insurer":{"slug":"iffco-tokio-general-insurance","name":"IFFCO TOKIO General Insurance Company Limited"},"source_pdf":"https://www.iffcotokio.co.in/content/dam/iffcotokio/iffco-pdf/sites/default/files/director-and-key-personnel-liability-insurance-claims-form.pdf","sha256":"a68073ee6b51c5a07b501e353b654e9597930e8bc2890fbbae933a8bd7bdca20","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming under the Director and Key Personnel Liability Insurance policy. It is to be filled and signed by the policyholder, who is the Director or Officer.","notes":["The form must be completed and signed by the policyholder (Director or Officer).","All questions must be answered fully; use additional sheets if necessary.","Attach copies of relevant documentation.","The form is 3 pages long."],"title":"Claims Form- Director and Key Personnel Liability Insurance","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Directors/Officers giving notification of a claim or potential claim","fields":[{"help":"","type":"text","label":"Insured Name","options":[],"required":null,"pdf_field":""},{"help":"Provide full name, address, and contact number","type":"text","label":"Name,Address and Contact Number of Directors/Officers giving notification","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"List all insured persons involved","type":"text","label":"(a) Full Name of Insured Person(s) who is/are the subject of the claim or potential Claim","options":[],"required":null,"pdf_field":""},{"help":"Provide full name and address of the organisation/entity","type":"text","label":"(b) Name of the Organisation/Entity of which such Insured Person(s) is/are a Director/Officer which is the subject matter of the claim notification","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other relevant insurance policies held by the organisation/entity","type":"text","label":"(c) Is the Organisation/Entity/Subsidiary/Outside Entity/ or any other body obtained a Director’s & Officer’s Liability insurance policy/ Or any other liability policy which provides coverage for you which can be triggered for the subject claim notification? Please confirm and provide the applicable policy details with underlying limits","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other D&O insurance policies held individually","type":"text","label":"(d) Apart from the Director’s & Officer’s Liability insurance policy obtained by Organisation/Entity/Subsidiary/Outside Entity/ or any other body (if applicable), Do you as individual Director or Officer obtained any other D&O Liability insurance policy for you which can be triggered for the subject claim notification? Please confirm and provide applicable the policy details with underlying limits","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder (Director or Officer)"},{"title":"The Details of Claimant","fields":[{"help":"Provide full name of the claimant","type":"text","label":"(a) Full Name of the Claimant or Potential Claimant (i.e. the party making the claim upon the Insured)","options":[],"required":null,"pdf_field":""},{"help":"Provide full address and contact number","type":"text","label":"(b) Address and contact number of the claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder (Director or Officer)"},{"title":"Details of the subject activity","fields":[{"help":"Describe the activity that led to the claim","type":"text","label":"(a) From what activity on the part of the insured does the claim or potential claim arise?","options":[],"required":null,"pdf_field":""},{"help":"Attach copy if available or describe details","type":"text","label":"(b) Was the performance or undertaking of such activity evidenced in writing? If so, please attach a copy. If not, please provide appropriate particulars","options":[],"required":null,"pdf_field":""},{"help":"Provide dates or duration of the activity","type":"text","label":"(c) When was the activity, from which the claim arises or may arise, performed or undertaken (duration)?","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder (Director or Officer)"},{"title":"Details of Claim or Circumstance","fields":[{"help":"Describe the claim or circumstances in detail","type":"text","label":"1. What is the precise nature of the claim (i.e. the claimant’s allegations) or the fact or circumstances that might give rise to a claim?","options":[],"required":null,"pdf_field":""},{"help":"Provide the date of first awareness","type":"date","label":"2. On what date did you first become aware of the claim or of such fact or circumstances?","options":[],"required":null,"pdf_field":""},{"help":"Provide the date when claim was first intimated","type":"date","label":"3. On what date was the claim or the intimation of a claim first made against you?","options":[],"required":null,"pdf_field":""},{"help":"Select how the claim was first intimated","type":"choice","label":"4. (a) was the first intimation of the claim verbal or in writing (if in writing please attach copy)","options":["verbal","in writing"],"required":null,"pdf_field":""},{"help":"Specify the amount claimed if applicable","type":"amount","label":"5. Amount claimed, if any?","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder (Director or Officer)"},{"title":"Details of Insured’s Response","fields":[{"help":"Provide your response or comments","type":"text","label":"(a) What are your comments in response to the claim or the fact or circumstances that might give rise to a claim?","options":[],"required":null,"pdf_field":""},{"help":"Provide your estimate of liability and comments on claim amount","type":"text","label":"(b) What are your comments on the quantum of the claim and what is your estimate of your potential monetary liability, if any, to the claimants?","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant information and attach supporting documents","type":"text","label":"(c) Are there additional details about which you wish to advise, or which may be of interest to IFFCO-TOKIO, so that IFFCO-TOKIO will have a better understanding of this matter? If so, please provide details alongwith supporting documentation","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder (Director or Officer)"},{"title":"Enclosures","fields":[{"help":"List attached documents","type":"text","label":"1.","options":[],"required":false,"pdf_field":""},{"help":"List attached documents","type":"text","label":"2.","options":[],"required":false,"pdf_field":""},{"help":"List attached documents","type":"text","label":"3.","options":[],"required":false,"pdf_field":""},{"help":"List attached documents","type":"text","label":"4.","options":[],"required":false,"pdf_field":""},{"help":"List attached documents","type":"text","label":"5.","options":[],"required":false,"pdf_field":""},{"help":"List attached documents","type":"text","label":"6.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Sign here","type":"signature","label":"I/We, ____________________________________________________ the above named, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every respect; and I/We agree that if I/We have made, or in any further declaration the Company may require in respect of the said accident, shall make any false or fraudulent statement, or any suppression or concealment, my/our claim shall be absolutely forfeited, and the Policy shall be null and void. Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder (Director or Officer)"}],"deadlines":[],"applies_to":"Director and Key Personnel Liability Insurance claims","attachments":["Copy of written evidence of activity if available","Copy of first intimation of claim if in writing","Supporting documentation related to the claim or additional details"],"declarations":["The statements made in this form are true to the best of the claimant's knowledge and belief.","If any false or fraudulent statement or concealment is made, the claim will be forfeited and the policy void."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"policy issuing Branch","label":"Walk in claim intimation","level":null,"hours":"Mon- Fri 09:30 AM to 06:00 PM (Except for National Holidays)","applies_to":"all","source_url":"https://www.iffcotokio.co.in/claims/register-a-claim","quote":"65 days.\nToll No. 1800-103-5499\nWalk in\nShall you wish to intimate your claim in person, please feel free to visit your policy issuing Branch Mon- Fri 09:30 AM to 06:00 PM (Except for National Holidays). Please refer to our\nBranch Locator\nfor information on our","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"support@iffcotokio.co.in","label":"Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.iffcotokio.co.in/contact-us/customer-services/grievance-redressal","quote":"se\nTelugu\nOriya\nPolicy Copy\nService Request\nLocators\nClaims\nRegister Claim\nClaim Status\nToll free: 1800-103-5499\nEmail: support@iffcotokio.co.in\nSay Hi to IRA: 7993407777\nEnglish\nHindi\nMarathi\nGujarati\nPunjabi\nMalayalam\nTamil\nBengali\nKannada\nAssamese\nTelugu\nOriya","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-5499","label":"Toll free","level":null,"hours":"24 X 7","applies_to":"all","source_url":"https://www.iffcotokio.co.in/contact-us/customer-services/grievance-redressal","quote":"engali\nKannada\nAssamese\nTelugu\nOriya\nPolicy Copy\nService Request\nLocators\nClaims\nRegister Claim\nClaim Status\nToll free: 1800-103-5499\nEmail: support@iffcotokio.co.in\nSay Hi to IRA: 7993407777\nEnglish\nHindi\nMarathi\nGujarati\nPunjabi\nMalayalam\nTamil\nBengal","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"sms","value":"56161","label":"SMS “CLAIM” to 56161","level":null,"hours":null,"applies_to":"all","source_url":"https://www.iffcotokio.co.in/claims/register-a-claim","quote":"avor to take customer service at newer heights, we now bring claim Intimation at your fingertips. Please SMS “CLAIM” to 56161 and one of our Claims representatives will get in touch with you in 4 Working Hours.\n* Note:\nPlease have all the detail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"whatsapp","value":"7993407777","label":"Say Hi to IRA","level":null,"hours":null,"applies_to":"all","source_url":"https://www.iffcotokio.co.in/contact-us/customer-services/grievance-redressal","quote":"est\nLocators\nClaims\nRegister Claim\nClaim Status\nToll free: 1800-103-5499\nEmail: support@iffcotokio.co.in\nSay Hi to IRA: 7993407777\nEnglish\nHindi\nMarathi\nGujarati\nPunjabi\nMalayalam\nTamil\nBengali\nKannada\nAssamese\nTelugu\nOriya\nCustomer Login\nAgent Login","fetched_at":"2026-10-20"}],"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/iffco-tokio-general-insurance/312-claims-form-director-and-key-personnel-liability-insurance"}