{"id":382,"title":"CLAIM FORM EMPLOYEE DISHONESTY LIABILITY INSURANCE POLICY","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/employee-dishonesty-liability-commercial.pdf","sha256":"930e04233d7d67007d63c2611f56304f6a390a3eac79cc29011322e6e06e4160","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for losses under the Employee Dishonesty Liability Insurance policy.","notes":["The insured must provide information and cooperation as reasonably required by the insurer as a condition precedent to liability.","The intimation is without prejudice and the insurer's rights are reserved."],"title":"CLAIM FORM EMPLOYEE DISHONESTY LIABILITY INSURANCE POLICY","submit":{"to":"","how":"","address":""},"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":"Enter the start date of the policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Limit Of Liability","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Provide a detailed description of the loss; attach separate pages if required","type":"text","label":"Description of the Loss","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured entity","type":"text","label":"Name of Entity","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss was discovered","type":"date","label":"Date of Discovery","options":[],"required":null,"pdf_field":""},{"help":"Explain how the loss was discovered","type":"text","label":"Circumstances leading to discovery of Loss","options":[],"required":null,"pdf_field":""},{"help":"Provide an estimated amount of the loss","type":"amount","label":"Estimated Quantum of Loss","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 above is Yes","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Status of proceedings as on date","fields":[{"help":"Describe the current status of any proceedings related to the claim","type":"text","label":"Status of proceedings as on date","options":[],"required":null,"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":"If Yes, provide details of other insurance","type":"text","label":"Type of Cover:","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Name of insured under other policy","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"Start date of other policy","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Date when notified to other insurer","type":"date","label":"If Yes, please provide the below details Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Authorized signatory to sign and date the form","type":"signature","label":"For and on Behalf of","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Employee Dishonesty Liability Insurance","attachments":["Professional opinion & Investigation report taken by the insured","Loss Calculation","Separate pages if required for Description of the Loss"],"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.","Consent is given to the insurer to seek necessary information/documents from any third party who has made a claim against the insured.","Consent is given to the company to verify and obtain identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes."],"dropped_labels":3},"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/382-claim-form-employee-dishonesty-liability-insurance-policy"}