{"id":394,"title":"PROPOSAL FORM PRODUCTS RECALL GUARANTEE AND FINANCIAL LOSS LIABILITY INSURANCE","purpose":"proposal","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/26-product-recall-guarantee-and-financial-loss-liability-insurance8c0007ff45fd68ff8a0df0055fa61771.pdf","sha256":"cc9a0be8ecf09be53add52e160e9d71533a7a37cdc676b3ad972121486463e48","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is a proposal for Products Recall Guarantee and Financial Loss Liability Insurance to be filled by the company proposing to be insured.","notes":["Politically Exposed Persons (PEPs) are defined and must be declared if applicable","The form is for commercial insurance proposal for products recall guarantee and financial loss liability","No fillable PDF fields were identified","Statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938 is included"],"title":"PROPOSAL FORM PRODUCTS RECALL GUARANTEE AND FINANCIAL LOSS LIABILITY INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter the full legal name of the company to be insured","type":"text","label":"Full Name of Company proposed to be insured","options":[],"required":null,"pdf_field":""},{"help":"Enter the complete mailing address of the proposer","type":"text","label":"Mailing Address","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Politically Exposed Person (PEP) Declaration","fields":[{"help":"Provide details only if answered Yes above","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Deductible Desired","fields":[{"help":"Specify the deductible amount desired","type":"text","label":"Deductible desired","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank and Identification Details","fields":[{"help":"Enter name exactly as per bank records","type":"text","label":"Proposed policyholder’s name (as per bank record)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Proposed policyholder’s account no.","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter 9 digit MICR code","type":"number","label":"MICR Code (9 digit)","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN card number","type":"text","label":"PAN card no. of the proposed policyholder","options":[],"required":null,"pdf_field":""},{"help":"Enter 11 digit IFSC code","type":"text","label":"IFSC Code (11 digit)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Consent to KYC verification is mandatory","type":"checkbox","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 through Central KYC Registry or UIDAI or through any other modes for the purpose of undertaking KYC.","options":["I/We consent"],"required":true,"pdf_field":""},{"help":"Declaration of legal source of funds is mandatory","type":"checkbox","label":"I/We hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of income.","options":["I/We declare"],"required":true,"pdf_field":""},{"help":"Acknowledgement of Company's right to verify source of funds","type":"checkbox","label":"I/We understand that the Company has right to call for documents to establish source of funds","options":["I/We understand"],"required":true,"pdf_field":""},{"help":"Declaration of truthfulness and obligation to update information","type":"checkbox","label":"I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to inform you of any changes therein, immediately, not later than 30 days.","options":["I/We declare"],"required":true,"pdf_field":""},{"help":"Acknowledgement of liability for false information","type":"checkbox","label":"In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am/we are aware that I/we may be held liable for it.","options":["I/We acknowledge"],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":["Inform the insurer of any changes in information immediately, not later than 30 days"],"applies_to":"Commercial Products Recall Guarantee and Financial Loss Liability Insurance policies","attachments":[],"declarations":["Consent to KYC verification through Central KYC Registry or UIDAI or other modes","Declaration that premium is paid from legally acquired sources and future premiums will be similarly paid","Acknowledgement that the company can call for documents to establish source of funds","Declaration that all information provided is true and correct and obligation to inform changes within 30 days","Awareness of liability if any information is false, untrue, misleading or misrepresenting"],"dropped_labels":2},"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/394-proposal-form-products-recall-guarantee-and-financial-loss-liability-insurance"}