{"id":396,"title":"Credit / Debit / ATM Card Package Insurance Policy CLAIM FORM","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/credit-debit-atm-card-package-insurance-policy-commercial.pdf","sha256":"780fb59030ab4777567c379fb5567b3d78931a86b7e96eec0896df5b9b4dc1e1","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for notifying and claiming physical loss or damage under the Credit/Debit/ATM Card Package Insurance Policy. It is filled by the insured policyholder.","notes":["The issue of this form is not an admission of liability by the insurer.","Please furnish a copy of the FIR with the claim form."],"title":"Credit / Debit / ATM Card Package Insurance Policy CLAIM FORM","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Office Address","options":[],"required":null,"pdf_field":""},{"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":false,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"i. Name","options":[],"required":true,"pdf_field":""},{"help":"Occupation of the insured person","type":"text","label":"ii. Occupation","options":[],"required":true,"pdf_field":""},{"help":"Correspondence address of the insured","type":"text","label":"iii. Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"Phone number of the insured","type":"phone","label":"iv. Contact No.","options":[],"required":true,"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 of PEP*?","options":["Yes","No"],"required":true,"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":"Details of Loss or Damage","fields":[{"help":"Describe the type of loss or damage","type":"text","label":"2. Nature of loss/ damage.","options":[],"required":true,"pdf_field":""},{"help":"Location where the loss or damage occurred","type":"text","label":"3. Place & address where the loss took place.","options":[],"required":true,"pdf_field":""},{"help":"Last known time and place of the property","type":"text","label":"4. When and where was the missing property last seen?","options":[],"required":true,"pdf_field":""},{"help":"Date and time loss was noticed","type":"date","label":"5. Date and time when loss was first discovered.","options":[],"required":true,"pdf_field":""},{"help":"Explain how the loss or damage happened","type":"text","label":"6. State the circumstances of the loss or damage.","options":[],"required":true,"pdf_field":""},{"help":"Approximate monetary value of lost or damaged items","type":"amount","label":"7. Estimated value of items lost or damaged","options":[],"required":true,"pdf_field":""},{"help":"Date and time when loss was reported to police","type":"date","label":"8. Date and time of reporting the loss to Police Station. (Please furnish copy of FIR)","options":[],"required":true,"pdf_field":""},{"help":"Police station where FIR was filed","type":"text","label":"9. Name and address of the Police Station.","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you are the only owner","type":"yes-no","label":"10. Are you the sole owner of the property?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide details if previous similar loss occurred","type":"text","label":"11. Have you ever before sustained loss of the same nature? If so, give particulars.","options":[],"required":false,"pdf_field":""},{"help":"Details of any other insurance covering the property","type":"text","label":"12. Is there any other insurance on the same property? If so, give full particulars","options":[],"required":false,"pdf_field":""},{"help":"Any other relevant information","type":"text","label":"13. Any additional information relevant to processing of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Consent","fields":[{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing the form","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Credit/Debit/ATM Card Package Insurance Policy","attachments":["Copy of FIR (First Information Report) from Police"],"declarations":["The information given in this claim form is true, correct and complete.","All persons having interest in the property are disclosed as per the proposal or policy endorsement.","No similar claim has been made to any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or concealed.","False or fraudulent statements will void the policy and claims rights.","Receipt of this form does not mean acceptance of the claim; the company may require more information.","Consent is given to verify identity and address proofs through Central KYC Registry, 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/396-credit-debit-atm-card-package-insurance-policy-claim-form"}