{"id":362,"title":"ICICI LOMBARD MOTOR INSURANCE CLAIM FORM","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/claims-form8c0007ff45fd68ff8a0df0055f853edc.pdf","sha256":"0d553c8a127ff38bc5131f188b1e25ea2ee0b03d3ee78e30eb307324423e0602","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured vehicle owner or claimant to file a motor insurance claim with ICICI Lombard General Insurance Company Limited.","notes":["Issuing this form does not mean the claim has been approved.","For assistance or to know your claim number, call the Toll-Free Helpline: 1800 2666.","Use the contact details and addresses printed on the form for communication.","The form includes office addresses and contact details for ICICI Lombard General Insurance Company Limited."],"title":"ICICI LOMBARD MOTOR INSURANCE CLAIM FORM","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Claim Details","fields":[{"help":"Enter your insurance policy or cover note number.","type":"text","label":"Policy / Cover Note Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the claim number if you have it.","type":"text","label":"Claim Number (if available):","options":[],"required":false,"pdf_field":""},{"help":"Enter the full name of the insured person.","type":"text","label":"Name of the Insured:","options":[],"required":true,"pdf_field":""},{"help":"Enter a valid mobile number for communication.","type":"phone","label":"Mobile Number: (for communication)","options":[],"required":true,"pdf_field":""},{"help":"Enter a valid email address.","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Enter the make/brand of the vehicle.","type":"text","label":"Vehicle Make:","options":[],"required":true,"pdf_field":""},{"help":"Enter the vehicle's chassis number.","type":"text","label":"Chassis Number:","options":[],"required":true,"pdf_field":""},{"help":"Enter the model of the vehicle.","type":"text","label":"Vehicle Model:","options":[],"required":true,"pdf_field":""},{"help":"Enter the date when the accident occurred.","type":"date","label":"Date of Accident:","options":[],"required":true,"pdf_field":""},{"help":"Enter the time when the accident occurred (e.g. HH:MM).","type":"text","label":"Time of Accident:","options":[],"required":true,"pdf_field":""},{"help":"Provide the exact location or landmark of the accident.","type":"text","label":"Exact Location of Accident (Address / Landmark)","options":[],"required":true,"pdf_field":""},{"help":"Select whether the vehicle was parked or moving at the time of accident.","type":"choice","label":"Vehicle Status at the Time of Accident","options":["Parked","Moving"],"required":true,"pdf_field":""},{"help":"Provide a short description of how the accident happened.","type":"text","label":"Brief Description of the Accident:","options":[],"required":true,"pdf_field":""},{"help":"Indicate if any third party was injured in the accident.","type":"yes-no","label":"Any Third-Party Injury?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"claimant / insured"},{"title":"Driver Details (at the time of accident)","fields":[{"help":"Select who was driving the vehicle at the time of accident.","type":"choice","label":"Vehicle was being driven by:","options":["Vehicle Owner","Other than Owner"],"required":true,"pdf_field":""},{"help":"Enter the full name of the driver at the time of accident.","type":"text","label":"Name of Driver:","options":[],"required":true,"pdf_field":""},{"help":"Enter the driving licence number of the driver.","type":"text","label":"Driving Licence Number:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant / insured"},{"title":"Third-Party Injury / Property Damage (if applicable)","fields":[{"help":"Enter the name of the injured third party, if any.","type":"text","label":"Name of Injured Person / Third Party","options":[],"required":false,"pdf_field":""},{"help":"Enter the address of the injured third party.","type":"text","label":"Address:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if an FIR was lodged for the accident.","type":"yes-no","label":"FIR Lodged:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter the police station name where FIR was lodged.","type":"text","label":"Name of Police Station:","options":[],"required":false,"pdf_field":""},{"help":"Enter the FIR number if available.","type":"text","label":"FIR Number:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant / insured"},{"title":"Garage Details","fields":[{"help":"Indicate if the vehicle was reported to a garage.","type":"yes-no","label":"Vehicle Reported to Garage:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter the name of the garage where vehicle was reported.","type":"text","label":"Garage Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter the address or location of the garage.","type":"text","label":"Garage Location / Address:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant / insured"},{"title":"Declarations and Consent","fields":[{"help":"Enter the date of signing the form.","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form to declare the information is true and consent to terms.","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant / insured"}],"deadlines":[],"applies_to":"motor insurance claims","attachments":[],"declarations":["The details furnished are true and correct to the best of my/our knowledge and belief.","I/we understand that false or misleading information may lead to cancellation of insurance and forfeiture of claim.","I/we have submitted all required documents and understand the requirements for claim processing.","Information provided electronically is sufficient and physical signature is not mandatory for claim processing.","I/we agree to provide additional information/documents if required by the company.","Receipt of documents does not guarantee claim approval; company may request further information or reject claim.","I/we consent to verification of identity/address through Central KYC Registry or UIDAI for KYC purposes.","I/we consent to sharing of documents/information with garage or surveyor for claim settlement.","I/we understand the option to retain the wreck and accept cash loss settlement for eligible claims.","I/we will not claim input credit of GST paid by ICICI Lombard in settlement of this motor insurance claim."],"dropped_labels":0},"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/362-icici-lombard-motor-insurance-claim-form"}