{"id":393,"title":"INCIDENT REPORTING FORM OF PROFESSIONAL INDEMNITY POLICY FOR DOCTORS & MEDICAL PRACTITIONERS","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-doctors-and-medical-practitioners-retail.pdf","sha256":"5e9c9eba4edb0151ebdb232caf7c22232af1e1edc7a4c8f674efc95a3ab5afcf","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is for doctors and medical practitioners insured under the Professional Indemnity Policy to report incidents that may lead to a claim. The insured person fills it.","notes":["The issue of the form is not to be taken as an admission of liability.","Do not delay submission if all particulars are not immediately available; forward missing information as soon as possible.","Insured shall not enter into compromise/settlement without written permission of the Company.","Attach written complaint/notice given by claimant where applicable.","Attach separate sheets if space is insufficient.","Use the toll free number or email for claim intimation and follow instructions for FIR, surveyor appointment, and document submission.","Assessment and claim decision timelines are provided (assessment within 15 days, decision within 7 days after assessment)."],"title":"INCIDENT REPORTING FORM OF PROFESSIONAL INDEMNITY POLICY FOR DOCTORS & MEDICAL PRACTITIONERS","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064; Email: customersupport@icicilombard.com"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Specify your medical classification","type":"text","label":"Classification of Medical Practitioner (Physician, Pathalogist etc)","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number with country/area code","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Person as defined","type":"yes-no","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":"Describe relationship and position","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claimant","fields":[{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Claimant's full address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Claimant's phone number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Describe the medical service given","type":"text","label":"Mention the type of professional service provided to the Claimant in detail","options":[],"required":null,"pdf_field":""},{"help":"Specify diagnosed illness","type":"text","label":"Nature of Disease/Illness diagnosed","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment provided","type":"text","label":"Details of treatment given to claimant","options":[],"required":null,"pdf_field":""},{"help":"Date of service","type":"date","label":"When was the service provided to Claimant","options":[],"required":null,"pdf_field":""},{"help":"Claimant's relation or role","type":"text","label":"Please specify the capacity in which the claimant is making/can make the claim against you","options":[],"required":null,"pdf_field":""},{"help":"Date and manner of first knowledge","type":"text","label":"When and how did you first come to know of the error/omission","options":[],"required":null,"pdf_field":""},{"help":"Describe incident briefly","type":"text","label":"Brief description of the incident which can lead to claim","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance policies if applicable","type":"text","label":"Give particulars of any other insurance, if any in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Alleged Claim","fields":[{"help":"Date and time of alleged incident","type":"date","label":"Alleged Date & Time of Error/Omission/negligence","options":[],"required":null,"pdf_field":""},{"help":"Name of alleged person","type":"text","label":"Name of the person who has been alleged for Error/Omission","options":[],"required":null,"pdf_field":""},{"help":"Designation of alleged person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Qualification of alleged person","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Describe the event briefly","type":"text","label":"Brief description of the event","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claimant (continued)","fields":[{"help":"Provide claimant details; attach extra sheet if needed","type":"text","label":"Give name/es, address/es occupation/s of Claimant (Attach separate sheet, if space not sufficient )","options":[],"required":null,"pdf_field":""},{"help":"Describe injury or loss; attach extra sheet if needed","type":"text","label":"Details of Injury/death/damage/loss to the claimant (Attach separate sheet, if space not sufficient )","options":[],"required":null,"pdf_field":""},{"help":"Count of victims involved","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Claimant's capacity and attach complaint/notice","type":"text","label":"Mention the capacity under which the claim is being made by the claimant (Attach the written complaint/notice given by the claimant)","options":[],"required":null,"pdf_field":""},{"help":"Compensation amount claimed","type":"amount","label":"Mention the amount of compensation claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Compromise Details","fields":[{"help":"State if you accept liability","type":"yes-no","label":"Do you agree that you are liable for the incident.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain reasons for your answer","type":"text","label":"Give reasons","options":[],"required":null,"pdf_field":""},{"help":"Explain reasons and strategy for compromise or settlement","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game-plans/strategy for the same.","options":[],"required":null,"pdf_field":""},{"help":"Current status of negotiations","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"Amount of liability proposed","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"Indicate if any legal case filed","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the incident ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if court notices received and attach copies if yes","type":"yes-no","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of parties involved","type":"text","label":"Details of the main Parties of the leagal Proceedings","options":[],"required":null,"pdf_field":""},{"help":"Indicate if court orders passed and attach copies if yes","type":"yes-no","label":"Has the court passed any interim or final order? If yes, please provide copies of the same","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach all court documents submitted","type":"attachment","label":"Also provide copies of all the documents that have been submitted to the Court either by you or the Claimants.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Legal Advice","fields":[{"help":"Describe your response to the claim","type":"text","label":"The Insured's proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if legal advice obtained or planned","type":"yes-no","label":"Does the insured propose to/has already availed of, any legal advise.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide lawyer details and opinion","type":"text","label":"If Yes, details of the lawyer/law firm together with their opinion","options":[],"required":null,"pdf_field":""},{"help":"Describe planned steps to evaluate legal risk","type":"text","label":"If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":null,"pdf_field":""},{"help":"Estimate of legal costs","type":"amount","label":"Estimated Legal/Defence Cost/fees which will be incurred","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"Provide any additional evidence","type":"text","label":"Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance if any","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Settlement Details","fields":[{"help":"Settlement amount agreed","type":"amount","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants?","options":[],"required":null,"pdf_field":""},{"help":"Attach proof documents","type":"attachment","label":"Please provide proof of the following (agreement, understanding, court order, court award etc)","options":[],"required":null,"pdf_field":""},{"help":"Court imposed liability amount","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you?","options":[],"required":null,"pdf_field":""},{"help":"Attach court award copy","type":"attachment","label":"Please provide copy of the court award.","options":[],"required":null,"pdf_field":""},{"help":"Total defence costs incurred","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Final Declaration","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","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":"Professional Indemnity Policy for Doctors & Medical Practitioners","attachments":["copies of court notices/summons if any","copies of court orders if any","all documents submitted to court by insured or claimants","proof of settlement (agreement, understanding, court order, court award etc)","copy of court award if applicable"],"declarations":["The statements/information given in this form are true, correct and complete.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and rights to claim.","Receipt of this form or documents does not constitute agreement of the claim by the Company.","Consent is given to the Company to verify identity/address proof through Central KYC Registry or UIDAI or other modes."],"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/393-incident-reporting-form-of-professional-indemnity-policy-for-doctors-and-medical"}