{"id":374,"title":"CLAIM FORM FOR FIDELITY GUARANTEE 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-fidelity-guarantee-insurance-commercial.pdf","sha256":"0bbd3f5d6861d8294172efc846ab21156719422db9c38bc85182f007f3cf3824","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to claim under a Fidelity Guarantee Insurance policy for losses due to employee defalcation.","notes":["If space is insufficient for describing defalcation, attach a separate signed sheet.","Attach a certified statement of relevant book entries in order of dates.","Attach original blank cancelled cheque signed by payee for EFT.","Attach PAN card copy of payee for EFT.","Terms and conditions for RTGS/NEFT payments apply as printed on the form."],"title":"CLAIM FORM FOR FIDELITY GUARANTEE 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","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Defaulting Employee","fields":[{"help":"","type":"text","label":"Name of the defaulting employee in full","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"His present address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"","type":"amount","label":"Amount of loss sustained","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of discovery of the loss","options":[],"required":null,"pdf_field":""},{"help":"If multiple dates, list all","type":"date","label":"Date(s) of loss","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Defalcation","fields":[{"help":"Attach separate signed sheet and certified statement as described","type":"text","label":"How exactly was the defalcation committed? If space is not sufficient, please give full and detailed particulars on a separate signed sheet. (Also please attach a certified statement containing all entries in the Insured's books of accounts relative to the defalcation in the order of their dates).","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Duties at Time of Defalcation - Money","fields":[{"help":"","type":"text","label":"In what capacity was he engaged and where?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"How did the money reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"Specify amount and duration","type":"text","label":"What was the largest sum that he held in his hands at any one time and for how long?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was he allowed to pay out any amounts on the Insured's behalf?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name or designation of authoriser","type":"text","label":"Who authorised these payments?","options":[],"required":null,"pdf_field":""},{"help":"Explain frequency and person checking","type":"text","label":"Was he required to give printed receipts from a book with counterfoils? If so, how often were the counterfoils examined and checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain frequency and person checking","type":"text","label":"Were moneys paid into Bank by the defaulting employee? If so, how often were Bank Books examined and checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Specify amount if any","type":"text","label":"What balance, if any, was allowed to be kept in his hand?","options":[],"required":null,"pdf_field":""},{"help":"Describe process and frequency","type":"text","label":"How often were the Cash Accounts balanced and how was their accuracy checked? Please explain fully","options":[],"required":null,"pdf_field":""},{"help":"Specify frequency","type":"text","label":"How often were accounts sent direct to Customers independently of the employee?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Duties at Time of Defalcation - Stock","fields":[{"help":"","type":"text","label":"Did the employee have charge of stock? If so, in what way did stock reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"Explain authorisation process","type":"text","label":"Was he allowed to issue stores or materials independently? If not, who authorised these issues?","options":[],"required":null,"pdf_field":""},{"help":"Specify frequency","type":"text","label":"How often was the position of stock handled by the employee checked?","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"When was the last check made?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Audit and Security Details","fields":[{"help":"Include frequency, auditor name, and date","type":"text","label":"How often Account Book/ Stock Books were audited and by whom? When was the last audit done?","options":[],"required":null,"pdf_field":""},{"help":"List items and amounts","type":"text","label":"Has the Insured any moneys, estate, or effects of the employee in his possession? If so, give particulars with amounts.","options":[],"required":null,"pdf_field":""},{"help":"Describe security and amount","type":"text","label":"Does the Insured hold any other security from the employee? If so, state its nature and amount.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Personal Details","fields":[{"help":"Describe family and property details","type":"text","label":"Is the defaulting employee a member of a joint family, or does he hold any property furniture or other effects? If so, give details.","options":[],"required":null,"pdf_field":""},{"help":"List names and addresses","type":"text","label":"Has the employee any near relatives? If so, give their names and addresses, if known.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Actions Taken","fields":[{"help":"Describe actions","type":"text","label":"Has the Insured taken any action against the employee? If so, state the nature of action taken.","options":[],"required":null,"pdf_field":""},{"help":"Describe enquiry and outcome","type":"text","label":"Has the Insured initiated Departmental Enquiry against the Employee? If so, state the outcome of the same.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Police Report","fields":[{"help":"Provide police station name and actions","type":"text","label":"Has the loss been reported to the Police? If so, state at which Police Station and what action was taken by Police.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Information","fields":[{"help":"","type":"text","label":"Any other relevant information.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Persons (PEP) Declaration","fields":[{"help":"Select Yes or No","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if Yes selected","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":"Declarations 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 Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Select Yes or No","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill all below fields if Yes selected","type":"text","label":"If yes, kindly provide the below mentioned details :","options":[],"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":"Select account type","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":"Mandatory attachment","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the Payee.","options":[],"required":true,"pdf_field":""},{"help":"Mandatory attachment","type":"attachment","label":"Please attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Fidelity Guarantee Insurance claims","attachments":["Certified statement containing all entries in the Insured's books of accounts relative to the defalcation in the order of their dates","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 concealment 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":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/374-claim-form-for-fidelity-guarantee-insurance"}