{"id":384,"title":"INCIDENT REPORTING FORM OF PROFESSIONAL INDEMNITY POLICY FOR MEDICAL ESTABLISHMENTS","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/professional-indemnity-for-medical-establishments-commercial.pdf","sha256":"03d9e243fb4c9ab22b2d263bd9bfa3d25ed2e0021f474a9c14138afa709287c7","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used to report an incident under the Professional Indemnity insurance policy for medical establishments. It is filled by the policyholder or the insured medical establishment.","notes":["Politically Exposed Persons (PEPs) are defined as individuals entrusted with prominent public functions by a foreign country, including heads of states, senior politicians, government/judicial/military officers, senior executives of state-owned corporations, and important political party officials."],"title":"INCIDENT REPORTING FORM OF PROFESSIONAL INDEMNITY POLICY FOR MEDICAL ESTABLISHMENTS","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"PEP Declaration","fields":[{"help":"Select Yes or No to indicate if any applicant is a Politically Exposed Person or related to one.","type":"choice","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 of the relationship and position if any applicant is a PEP.","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder or proposed applicants"},{"title":"Consent for KYC Verification","fields":[{"help":"Consent to allow the insurer to verify identity and address proofs for KYC purposes.","type":"yes-no","label":"I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof as well as the identity /address proof of the Insured / Beneficial Owner through Central KYC Registry or UIDAI or through any other modes for the purpose of undertaking KYC.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder or insured"}],"deadlines":[],"applies_to":"Professional Indemnity Policy for Medical Establishments","attachments":[],"declarations":["Consent to allow the insurer to verify identity and address proofs through official registries for KYC."],"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/384-incident-reporting-form-of-professional-indemnity-policy-for-medical-establishme"}