{"id":383,"title":"CLAIM FORM: GROUP SAFEGUARD 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/group-safeguard-insurance-claim-form.pdf","sha256":"62494f82b4bc0ef9de9a075c3066cd34005d099d29d0d47f79b618781113e8d0","pages":18,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the Group Safeguard Insurance policy with ICICI Lombard General Insurance Company Ltd.","notes":["Attach a separate sheet if space is insufficient for filling details.","Only last 4 digits of Aadhar number to be entered.","Nominee’s bank account details are required in case of a death claim.","KYC documents are mandatory if claim amount is greater than 1 lakh.","Use original bills and documents as specified for each benefit.","Submit all original hospitalization or day-care treatment-related documents if not submitted earlier.","Use block letters where applicable.","Claimant/Insured Person must sign the form and declarations.","For RTGS/NEFT payments, provide valid bank details and documents as specified.","Claim documents required vary by benefit and must be attached accordingly."],"title":"CLAIM FORM: GROUP SAFEGUARD INSURANCE","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post / e-mail / upload / in person / with the hospital (multiple options mentioned: website, toll free number, email, branch visit)","address":"Mailing Address: ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016; Email: ihealthcare@icicilombard.com; Website: www.icicilombard.com; Toll Free Number: 1800 2666"},"purpose":"claim","sections":[{"title":"Part I: Customer related details","fields":[{"help":"","type":"choice","label":"Gender: Male / Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Policyholder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Person","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of claimant (Please ignore if Insured Person is claimant)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship of claimant with Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address for communication","options":[],"required":null,"pdf_field":""},{"help":"Mobile and/or residential phone number","type":"phone","label":"Contact Details: Mob. / Res. No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"Provide insurer name, policy/product name, policy number, policy period, sum insured","type":"table","label":"Do You have any other insurance for similar claim (either with Us or with any other insurer) If yes please specify details","options":[],"required":null,"pdf_field":""},{"help":"Enter only last 4 digits of Aadhar","type":"number","label":"Aadhar Number: Only last 4 digits to be entered.","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Part I: Loan Details","fields":[{"help":"","type":"text","label":"LAN No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Loan disbursed amount","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Policy assigned: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please mention the name of financial institution","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant if policy is linked to an underlying loan"},{"title":"Part II: Claim Details","fields":[{"help":"","type":"text","label":"Claim No. (If claim has already been registered with ICICI Lombard Health Care)","options":[],"required":false,"pdf_field":""},{"help":"Describe the loss or event in detail","type":"text","label":"Description of Loss/Event","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Was any FIR done: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If FIR done, provide police station location","type":"text","label":"Location of police station in which FIR registered","options":[],"required":false,"pdf_field":""},{"help":"If FIR done, provide FIR number","type":"text","label":"FIR no.","options":[],"required":false,"pdf_field":""},{"help":"Explain why FIR was not filed if applicable","type":"text","label":"In case FIR was not done, please state the reasons for same","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Part III: Hospital Details","fields":[{"help":"","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of treating Medical Practitioner","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nature of Injury/Illness","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment details","type":"text","label":"Particulars of treatment","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY and time with AM/PM","type":"date","label":"Date and time of admission","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY and time with AM/PM","type":"date","label":"Date and time of discharge","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Number of days in ICU (if any)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Maternal Complication (if any)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Reasons for admission: Medical / Accidental","options":["Medical","Accidental"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"In case of admission due to Accident: Was any MLC done: Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"In case of death: Was any post mortem done: Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was Insured Person suffering from any Pre-Existing Disease","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Insured Person/claimant/Competent authority at treating Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person / claimant / Hospital authorities"},{"title":"Section A: Accidental Injury Benefits","fields":[{"help":"Tick all benefits you are claiming for","type":"checkbox","label":"Please tick mark against relevant Benefit","options":["Death Benefit","Permanent Total Disablement (PTD) Benefit","Permanent Partial Disablement (PPD) Benefit","Temporary Total Disablement (TTD) Benefit","Common Carrier Accident Benefit","Adventure Sports Benefit","Children's Education Grant Benefit","EMI Benefit","Loan protection Benefit","Mobility Benefit","Orphan Benefit","Repatriation of Mortal Remains Benefit","Counselling Benefit","Parental care Benefit","Repatriation in case of Permanent Disability Benefit"],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Section B: Animal, Reptile & Insect Attack Benefits","fields":[{"help":"Tick all benefits you are claiming for","type":"checkbox","label":"Please tick mark against relevant Benefit","options":["Death due to Animal, Insect & Reptile Attack Benefit","Permanent Total Disablement (PTD) due to Animal, Insect & Reptile Attack Benefit","Hospitalization Expenses due to Animal, Insect & Reptile Attack Reimbursement Benefit"],"required":null,"pdf_field":""},{"help":"Provide date and time of admission, discharge, number of bills submitted","type":"table","label":"Additional Loss Details","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Section C: Specific Vector Borne Disease or Malaria Benefit","fields":[{"help":"Tick all benefits you are claiming for","type":"checkbox","label":"Please tick mark against relevant Benefit","options":["Specific Vector Borne Disease Benefit","Specific Vector Borne Disease related Hospitalization Benefit","Malaria Benefit","Malaria related Hospitalization Benefit"],"required":null,"pdf_field":""},{"help":"Select the diagnosed disease","type":"checkbox","label":"Tick against the diseases","options":["Dengue","Chickungunya","Kala-Azar","Japanese encephalitis","Filariasis"],"required":null,"pdf_field":""},{"help":"Provide date and time of admission and discharge","type":"table","label":"Additional Loss Details","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Section D: Maternal Complication Benefit","fields":[{"help":"Select the applicable complication or specify if other","type":"choice","label":"Please select the type of Maternal Complication","options":["Eclampsia","Abrupto Placenta","Placenta Increta","Placenta Percreta","Amniotic Fluid Embolism","Acute Fatty Liver of Pregnancy","Disseminated Intravascular Coagulation","Still Birth","Pre Eclampsia","Medical Termination of Pregnancy","Hyperemesis Gravidarum","Ectopic Pregnancy","Any other maternal complication"],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of conception","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY and time","type":"date","label":"Date and time of admission","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY and time","type":"date","label":"Date and time of discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Section E: Hospital Daily Cash - Illness","fields":[{"help":"Tick all benefits you are claiming for","type":"checkbox","label":"Please tick mark against relevant Benefit","options":["Hospital Daily Cash Benefit","Intensive Care Unit (ICU) Cash Benefit","Emergency Medical Services Benefit"],"required":null,"pdf_field":""},{"help":"Provide number of days, dates of admission and discharge, location and travel dates as applicable","type":"table","label":"Additional Loss Details","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Part IV: NEFT Details","fields":[{"help":"","type":"text","label":"Claimant /Insured Person’s name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Claimant /Insured Person’s bank account no.","options":[],"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":"","type":"text","label":"IFSC code no. of the bank (should be same as per the provided cheque leaflet)","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Insured Person"},{"title":"Part V: KYC (Know Your Customer)","fields":[{"help":"","type":"text","label":"Claimant/Insured Person's Name (in respect of whom claim is made)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Claim Number (if allotted)","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile/ Contact No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""},{"help":"Attach two passport size photos","type":"photo","label":"Two passport size photos of Insured Person/claimant (stick in the space provided)","options":[],"required":true,"pdf_field":""},{"help":"Attach one valid ID proof","type":"attachment","label":"One photocopy of proof of identity of Insured Person/claimant (any 1 in the list)","options":["Passport","PAN card","Voter’s Identity card","Driving license","Personal identification and certification of the employees of the insurer","Job card issued by NREGA duly signed by an officer of the State Government","Letter from a recognized Public Authority or Public Servant verifying identity and residence"],"required":true,"pdf_field":""},{"help":"Attach one valid residence proof","type":"attachment","label":"One photocopy of proof of residence of Insured Person/claimant (any 1 in the list)","options":["Electricity bill","Ration card","Letter from any recognized public authority","Current statement of bank account with address","Current passbook with address (updated upto previous month)","Valid lease agreement along with rent receipt (not older than 3 months)","Telephone bill (not older than 6 months)","Employer’s certificate as proof of residence"],"required":true,"pdf_field":""}],"filled_by":"Claimant / Insured Person if claim amount is greater than 1 lakh"},{"title":"Claimant/Insured Person Declaration","fields":[{"help":"","type":"text","label":"Name of the Insured Person/claimant/Nominee","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relation with the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Insured Person"},{"title":"Consent Letter for Collection of Medical Records","fields":[{"help":"Enter your policy or proposal number","type":"text","label":"Proposal No. / Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured / Claimant","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Claimant / Insured Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person / claimant"}],"deadlines":[],"applies_to":"Group Safeguard Insurance claims","attachments":["Two passport size photos of Insured Person/claimant","One photocopy of proof of identity of Insured Person/claimant","One photocopy of proof of residence of Insured Person/claimant","Claim documents as per the benefits claimed (e.g. FIR, medical reports, hospital bills, discharge summary, post mortem report, loan documents, proof of travel, counseling certificates, educational certificates, etc.)","Cancelled cheque copy or bank attested copy of Passbook with IFSC code for NEFT payments","Self-attested copy of a valid government-issued identity proof of the Claimant/Insured along with the consent letter"],"declarations":["The statements/information provided in the claim form are true, correct and complete.","No material information relevant to claim processing has been withheld or not disclosed.","ICICI Lombard is authorized to collect medical and other relevant information for claim processing.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of claim form or documents does not imply admission of liability by ICICI Lombard.","The policy may be voided for untrue or incorrect statements or non-disclosure in claim documents.","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes.","Claimant/Insured undertakes to refund any excess amount credited in error within 7 days of notification.","Claim payment will be credited after confirmation from ICICI Lombard's bankers.","RTGS/NEFT payment terms and conditions apply as stated in the form."],"dropped_labels":2},"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/383-claim-form-group-safeguard-insurance"}