{"id":376,"title":"CLAIM FORM FOR HOME 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/home-insurance-claim-form8c0007ff45fd68ff8a0df0055f6a65d7.pdf","sha256":"15d7b8a82af04d7d997376a6d35ab81c680faee9a5eed10979a7df089eb06cef","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person to notify and claim for loss or damage under their home insurance policy.","notes":["Claim under 'Rent for alternative Accommodation' is admissible only if claim is registered and accepted on insured dwelling and dwelling declared unfit for occupation.","Use original documents and provide all required proofs.","Attach mandatory documents for Direct Fund Transfer/EFT as specified.","Submission of documents does not imply admission of liability by the company."],"title":"CLAIM FORM FOR HOME INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"Mailing Address: ICICI Lombard General Insurance Company Limited, Interface Building No.16, 601/602 6th Floor, New Link Road Malad (W), Mumbai - 400 064. Email: customersupport@icicilombard.com"},"purpose":"claim","sections":[{"title":"Basic Claim Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or damage occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"If already assigned","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Select the applicable claim section","type":"choice","label":"Claim Under Section","options":["Fire - Building & Contents / Earth quake Building & Contents / Additional expenses of rent for alternative accommodation","Burglary and/or theft"],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Full name of the policyholder","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Residential phone number","type":"phone","label":"Contact Number (R)","options":[],"required":null,"pdf_field":""},{"help":"Date and time when loss occurred","type":"date","label":"Date and Time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Date and time when loss was discovered","type":"date","label":"Date and Time of Discovery","options":[],"required":null,"pdf_field":""},{"help":"Brief description of cause or nature of loss","type":"text","label":"Cause/Reason/Nature of Loss","options":[],"required":null,"pdf_field":""},{"help":"Name of first witness if any","type":"text","label":"Details of Witness 1 - Name","options":[],"required":false,"pdf_field":""},{"help":"Describe the incident briefly","type":"text","label":"Brief description of incident","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other insurance covers this loss","type":"yes-no","label":"Other insurance on same Loss","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other insurance if applicable","type":"text","label":"If yes details","options":[],"required":false,"pdf_field":""},{"help":"List any previous claims under this policy","type":"text","label":"Previous losses under the policy","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information for Section 1 Claims (Fire, Earthquake, Rent)","fields":[{"help":"Answer Yes or No; if No, provide date","type":"text","label":"Whether the premises was occupied at the time of fire / loss ? Y/N, if No, Please provide the date from when it was vacant.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date from when premises was vacant if applicable","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Time from when premises was vacant if applicable","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Reason for removal or vacancy","type":"text","label":"Reason","options":[],"required":false,"pdf_field":""},{"help":"Answer Yes or No; if No, explain why","type":"text","label":"Has the fire / loss been reported to fire brigade and Police ? Y/N, if no, give reasons.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Police FIR number if reported","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if property is under loan or lease","type":"yes-no","label":"State whether the property damaged is Hypothecated / Lease / Hire purchase, If yes give details ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of party holding hypothecation if applicable","type":"text","label":"Hypothecation Party Name","options":[],"required":false,"pdf_field":""},{"help":"Duration of hypothecation","type":"text","label":"Period of such Hypothecation","options":[],"required":false,"pdf_field":""},{"help":"Loan amount on the property if any","type":"amount","label":"Value of such loan","options":[],"required":false,"pdf_field":""},{"help":"Value of any salvaged property","type":"amount","label":"State the value of Salvage, if any ?","options":[],"required":false,"pdf_field":""},{"help":"Total insured value of property at loss time","type":"amount","label":"State the total value of the property insured upon the premises at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss is due to earthquake and attach proof","type":"yes-no","label":"Is case loss reported is due to Earthquake? If Y, then submit the evidence of it.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if dwelling is uninhabitable","type":"yes-no","label":"Is the dwelling completely unfit for occupation after the occurrence of loss ? Y/N","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Rent amount paid or received","type":"amount","label":"What is the amount of rent paid / received by the insured","options":[],"required":false,"pdf_field":""},{"help":"Additional rent due to loss","type":"amount","label":"What is the additional rent to be paid by the insured as the consequence of loss","options":[],"required":false,"pdf_field":""},{"help":"Loss amount of rent (proof of tenancy required)","type":"amount","label":"What is the amount of loss of rent ?*","options":[],"required":false,"pdf_field":""},{"help":"Duration property was uninhabitable","type":"text","label":"What is the period of which property remained unfit for occupation","options":[],"required":false,"pdf_field":""},{"help":"Full address of loss location","type":"text","label":"Address of the premises at which loss occurred","options":[],"required":null,"pdf_field":""},{"help":"Details of any property removed for safety","type":"text","label":"Whether any property removed as an immediate Concern for further loss if yes give details","options":[],"required":false,"pdf_field":""},{"help":"Describe who occupied the premises at loss time","type":"text","label":"Occupation of the premises at the time of fire/loss","options":[],"required":false,"pdf_field":""},{"help":"Explain if not reported to fire brigade","type":"text","label":"Has the fire / loss been reported to fire brigade (If not give reasons)","options":[],"required":false,"pdf_field":""},{"help":"Additional details about damaged property","type":"text","label":"State whether the property so damaged","options":[],"required":false,"pdf_field":""},{"help":"Details if property is under loan or lease","type":"text","label":"If Hypothecated / Lease / Hire purchase if yes give details","options":[],"required":false,"pdf_field":""},{"help":"Location for inspection of loss","type":"text","label":"Address where the loss can be inspected","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information for Section 2 Claims (Burglary and/or Theft)","fields":[{"help":"Specify affected area of premises","type":"text","label":"Which portion of the premises affected by the entry/exit ?","options":[],"required":null,"pdf_field":""},{"help":"Details of police complaint if filed","type":"text","label":"Has a complaint been lodged with the police? If so, by whom and when and at which police station ?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if premises were occupied","type":"yes-no","label":"Were the premises occupied at the time of loss ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time last occupied if unoccupied","type":"text","label":"If not, on what date and at what hour were they last occupied ?","options":[],"required":false,"pdf_field":""},{"help":"Duration premises were unoccupied","type":"text","label":"For how long have the premises been unoccupied ?","options":[],"required":false,"pdf_field":""},{"help":"Details of any suspected persons","type":"text","label":"Is anybody suspected of theft ? If so, state full details.","options":[],"required":false,"pdf_field":""},{"help":"Name of other owners if any","type":"text","label":"If no, the property belongs to whom ?","options":[],"required":false,"pdf_field":""},{"help":"Indicate responsibility for repairs","type":"yes-no","label":"Is the insured responsible for repairs to the premises ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Total value of property and contents lost; details in Annexure 1","type":"amount","label":"State the total value of property upon the premises at the time of loss Value and description of contents lost, to be given in the annex 1.","options":[],"required":null,"pdf_field":""},{"help":"Additional information relevant to claim","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"PEP Declaration","fields":[{"help":"Answer if you or related persons are Politically Exposed Persons","type":"yes-no","label":"Are you or any of the proposed applicants a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of 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":"Place 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 the form here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Sign as account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Home insurance claims including fire, earthquake, burglary, theft, and additional expenses of rent for alternative accommodation.","attachments":["Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee","Proof of tenancy (if claiming loss of rent)","Annexure 1: Description of individual property damaged or contents lost"],"declarations":["The information given in this form is true, correct and complete.","The articles described belong to the insured and no other person has interest in them.","All persons having interest in the property are disclosed as per policy.","No material information relevant to the claim has been withheld.","False or fraudulent statements will void the policy and claims.","If property is recovered, the insured will refund any amount advanced by the company.","Receipt of this form does not constitute admission of claim liability.","Consent is given to verify identity/address through KYC registries."],"dropped_labels":8},"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/376-claim-form-for-home-insurance"}