{"id":392,"title":"CLAIM FORM FOR PROTECTION AND INDEMNITY 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-protection-and-indemnity-insurance8c0007ff45fd68ff8a0df0055fb0c5ab.pdf","sha256":"d7eabb625ea89fe117e8dd5fca0991562747939d2f4492ed4ffa39244adf252c","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage under Protection and Indemnity Insurance.","notes":["The issue of this form is not to be taken as an admission of liability.","To buy, renew, claim or service your policy, visit www.icicilombard.com or call 1800 2666.","The form does not specify submission address or method."],"title":"CLAIM FORM FOR PROTECTION AND INDEMNITY 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 was given","type":"yes-no","label":"Has any notice of Abandonment been given?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies if any","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":"Indicate if a Note of Protest was issued","type":"yes-no","label":"Has a Note of Protest been issued to the third party responsible for the incident.","options":["Yes","No"],"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 regarding Politically Exposed Person status","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 PEP is 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":"Location 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 the form here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Protection and Indemnity Insurance claims related to physical loss or damage","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 form or policy endorsement.","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 constitute admission of liability by the company.","Consent is given to the company to verify identity and address proofs through KYC registries."],"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/392-claim-form-for-protection-and-indemnity-insurance-notification-of-physical-loss-"}