{"id":388,"title":"CLAIM FORM FOR MARINE HULL INSURANCE Notification of Physical Loss or Damage","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/claim-form-marine-hull-insurance8c0007ff45fd68ff8a0df0055fb0c542.pdf","sha256":"09662e18f92a6ed895758caffc2a37f5f9bef41bb03ec54c6a3f7c7e5c695257","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for notifying and claiming physical loss or damage under a Marine Hull Insurance policy. It is filled by the insured policyholder.","notes":["The issue of this form is not an admission of liability.","Politically Exposed Persons (PEPs) are defined as individuals entrusted with prominent public functions by a foreign country.","To buy, renew, claim or service your policy, visit www.icicilombard.com or call 1800 2666."],"title":"CLAIM FORM FOR MARINE HULL INSURANCE Notification of Physical Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or damage occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"If already assigned","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the insured","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"Specify exact location of loss","type":"text","label":"State The name of Port/ Location (Latitude/ Longitude) where the Loss Occurred.","options":[],"required":null,"pdf_field":""},{"help":"Date and time when loss happened","type":"date","label":"Date and time of loss","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of the loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe any actions taken to mitigate loss","type":"text","label":"Details of remedial measures taken.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if salvage services were used","type":"yes-no","label":"Are any salvage services used.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if General Average was declared","type":"yes-no","label":"Whether General Average declared.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe damage to other ships or property","type":"text","label":"Details of damage to other Ships/Property.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Indicate if vessel declared Total Loss/Constructive Total Loss","type":"yes-no","label":"Has the vessel been declared a TL/CTL","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if notice of abandonment given","type":"yes-no","label":"Has any notice of Abandonment been given?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering this loss","type":"text","label":"Is there any other Insurance against the present loss under any other policy? If so, give full particulars.","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional information relevant to the claim","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member / Close relatives / Associates close relative of a PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe relationship and position if applicable","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":"Declarations and Signature","fields":[{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Marine Hull Insurance","attachments":[],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal or policy endorsement and no duplicate claims have been made.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this claim form or documents does not mean acceptance of the claim; the company may require more information or reject the claim.","Consent is given to the company to verify identity and address proofs through official registries for KYC purposes."],"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/388-claim-form-for-marine-hull-insurance-notification-of-physical-loss-or-damage"}