{"id":385,"title":"CLAIM FORM: GROUP SAFEGUARD MICRO 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-micro-insurance-claim-form8c0007ff45fd68ff8a0df0055f5f682f.pdf","sha256":"693adcaf0fd164da4fdfcab5500406b58008123299fece133a6da60e4a0b2e07","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 Micro Insurance policy.","notes":["Attach a separate sheet if space is insufficient for details.","Only last 4 digits of Aadhar number to be entered.","KYC documents required 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 collected at discharge.","Use block letters where applicable.","Claimant/Insured Person must sign the form and declarations.","NEFT details must match bank records and cheque/passbook.","Claims are eligible only for benefits for which premium has been received and specified in the policy certificate."],"title":"CLAIM FORM: GROUP SAFEGUARD MICRO INSURANCE","submit":{"to":"ICICI Lombard Healthcare","how":"mail / visit branch / online claim registration / email","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016; Email: ihealthcare@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":"Format: 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":false,"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":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was any FIR done: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please share Location of police station in which FIR registered","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"FIR no.","options":[],"required":false,"pdf_field":""},{"help":"","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":"Date format DD/MM/YYYY and time with AM/PM","type":"date","label":"Date and time of admission","options":[],"required":null,"pdf_field":""},{"help":"Date format 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":"Claim Sections and Benefits Selection","fields":[{"help":"Tick all benefits you are claiming for","type":"checkbox","label":"Please tick against each of the Benefit under which You are claiming for, as per the relevant Section and Benefits","options":["A.1.1 Death Benefit","A.1.2 Permanent Total Disablement (PTD) Benefit","A.1.3 Permanent Partial Disablement (PPD) Benefit","A.1.4 Temporary Total Disablement (TTD) Benefit","A.1.5 Common Carrier Accident Benefit","A.1.6 Adventure Sports Benefit","A.1.7 Children's Education Grant Benefit","A.1.8 EMI Benefit","A.1.9 Loan protection Benefit","A.1.10 Mobility Benefit","A.1.11 Orphan Benefit","A.1.12 Repatriation of Mortal Remains Benefit","A.1.13 Counselling Benefit","A.1.14 Parental care Benefit","A.1.15 Repatriation in case of Permanent Disability Benefit","A.2.1 Accidental Hospitalization Expenses Reimbursement Benefit","A.2.2 Accidental Pre & Post Hospitalization Expenses Benefit","A.2.3 Accidental Hospitalization Daily Cash Benefit","A.2.4 Air Ambulance Benefit","A.2.5 Comatose Benefit","A.2.6 Broken Bones Benefit","A.2.7 Compassionate Visit Benefit","A.2.8 Burns Benefit","A.2.9 Ambulance Charges Benefit","A.3.1 Assault Benefit","A.3.2 Mysterious Disappearance Benefit","B.1 Death due to Animal, Insect & Reptile Attack Benefit","B.2 Permanent Total Disablement (PTD) due to Animal, Insect & Reptile Attack Benefit","B.3 Hospitalization Expenses due to Animal, Insect & Reptile Attack Benefit","C.1 Specific Vector Borne Disease Benefit","C.1.1 Specific Vector Borne Disease related Hospitalization Benefit","C.2 Malaria Benefit","C.2.1 Malaria related Hospitalization Benefit","D Maternal Complication Benefit","E.1 Hospital Daily Cash Benefit","E.2 Intensive Care Unit (ICU) Cash Benefit","E.3 Emergency Medical Services Benefit"],"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":"IFSC code must match cheque or passbook","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 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":"Format: 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":"","type":"text","label":"Proposal No. / Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Person / Claimant","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant/Insured Person"}],"deadlines":[],"applies_to":"Group Safeguard Micro 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 selected benefits (e.g. FIR, MLC, hospital bills, discharge summary, medical certificates, loan documents, proof of travel, educational certificates, etc.)","Self-attested copy of a valid government-issued identity proof of the Claimant/Insured along with the consent letter","Cancelled cheque copy or bank attested copy of Passbook with IFSC code for NEFT"],"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 other modes.","Claimant 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.","Terms and conditions for NEFT/RTGS payments apply as stated in the form."],"dropped_labels":1},"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/385-claim-form-group-safeguard-micro-insurance"}