{"id":381,"title":"CLAIM FORM CYBER LIABILITY 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/cyber-liability-commercial.pdf","sha256":"8ef6083fb8ec86fd3ba12cea112a9e6e82e34355cccba2e1c32eef8b728150c6","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for losses under the Cyber Liability Insurance policy.","notes":["The insured must provide information and cooperation as reasonably required by the insurer.","The insured must not settle or assume any liability related to the claim without the insurer's prior written consent.","The intimation is without prejudice and the insurer's rights are reserved."],"title":"CLAIM FORM CYBER LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai - 400 064."},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Start date of the policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retroactively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Date related to prior and pending litigation","type":"date","label":"Prior and Pending Litigation Date","options":[],"required":null,"pdf_field":""},{"help":"Maximum liability limit under the policy","type":"amount","label":"Limit Of Liability","options":[],"required":null,"pdf_field":""},{"help":"Deductible amount applicable","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Describe the claim in detail","type":"text","label":"Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Location where the claim event occurred","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the wrongful act alleged","type":"text","label":"The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss occurred","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage alleged","type":"text","label":"The nature of the alleged damage","options":[],"required":null,"pdf_field":""},{"help":"List all claimants involved","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List all defendants involved","type":"text","label":"Defendants","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answer to previous question is Yes","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":"Additional Claim Information","fields":[{"help":"Provide estimated claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Provide a timeline of events related to the claim; attach separate pages if required","type":"text","label":"Chronology of Events","options":[],"required":false,"pdf_field":""},{"help":"Current status of any legal or claim proceedings","type":"text","label":"Status of proceedings as on date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Is there any other insurance that may be applicable to this notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Type of other insurance cover","type":"text","label":"Type of Cover","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Name of insured under other insurance","type":"text","label":"Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Attachments","fields":[{"help":"Attach copy of legal notice or written intimation","type":"attachment","label":"Copy of the legal notice/written intimation received by the Insured","options":[],"required":null,"pdf_field":""},{"help":"Attach any legal opinion obtained","type":"attachment","label":"Any legal opinion considered by the Insured","options":[],"required":false,"pdf_field":""},{"help":"Attach all correspondence related to the claim","type":"attachment","label":"Copy of the complete correspondence till date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Cyber Liability Insurance claims","attachments":["Copy of the legal notice/written intimation received by the Insured","Any legal opinion considered by the Insured","Copy of the complete correspondence till date"],"declarations":["The information furnished in this Claim Intimation Form is true, correct and complete to the best of the insured's knowledge.","If any untrue or false statement is made or material fact is concealed, the right to claim under the policy shall be forfeited.","The insured consents and authorizes the insurer to seek necessary information/documents from any third party who has made the claim.","The insured consents to the company verifying identity/address proof through Central KYC Registry or UIDAI or other modes."],"dropped_labels":5},"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/381-claim-form-cyber-liability-insurance"}