{"id":373,"title":"CLAIM FORM FOR MONEY 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/claim-form-for-money-insurance-commercial.pdf","sha256":"24475eff4b13e60c30aab5d959fc1a84091a8e255b235743ecd5342f1cefe780","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person to claim insurance for loss of money under a money insurance policy.","notes":["Attach copies of documents if employees are involved in the incident.","Attach an Original Blank Cancelled Cheque signed by the Payee for EFT.","Attach PAN Card copy of Payee for EFT.","Terms and conditions for payments through RTGS/NEFT are provided on the last page.","The form must be fully answered."],"title":"CLAIM FORM FOR MONEY INSURANCE","submit":{"to":"","how":"","address":""},"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":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"","type":"choice","label":"Did the loss occur when the money was kept in safe or whilst in transit?","options":["In Safe","In Transit"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"In whose custody was the money at the time of loss?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the money carried with an armed guard?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe any other security measures","type":"text","label":"Any other protection provided?","options":[],"required":null,"pdf_field":""},{"help":"Describe the method of carrying money","type":"text","label":"How was the money being carried?","options":[],"required":null,"pdf_field":""},{"help":"Specify the transport mode used","type":"text","label":"Means of transport","options":[],"required":null,"pdf_field":""},{"help":"Explain the situation leading to loss","type":"text","label":"Give the circumstances of loss","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"What is the amount of loss?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide police complaint registration number and station name","type":"text","label":"Have you informed the Police Authorities? Details of the C.R. No & name of the Police Station.","options":[],"required":null,"pdf_field":""},{"help":"Describe recovery efforts","type":"text","label":"Steps taken to recover the lost money","options":[],"required":null,"pdf_field":""},{"help":"Provide details and attach related documents","type":"text","label":"Whether any employee(s) has/have been involved in the incident? If so, the details of the action taken against him/ them like Police complaint, Departmental enquiry etc. (Please attach copies of documents)","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if any","type":"text","label":"Is there any other insurance upon the same money? If so give full particulars.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever before sustained loss of the same nature?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide policy details if applicable","type":"text","label":"Whether persons carrying money were covered under Fidelity Guarantee policy? If yes, details of the policy & issuing office.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""},{"help":"PEP means Politically Exposed Persons as defined on the form","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain relationship and position","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","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":"","type":"text","label":"Payee Name (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Payee Account No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Type of Account:","options":["Savings","Current","Others (specify)"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Name :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["copies of documents related to employee involvement if any","Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee"],"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 form or policy endorsement.","No material information relevant to the claim has been withheld or not disclosed.","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 purposes."],"dropped_labels":7},"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/373-claim-form-for-money-insurance"}