{"id":401,"title":"CLAIM FORM FOR SECURE MIND POLICY","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/4080_group-secure-mind-claim_form8c0003ff45fd68ff8a0df0055f2ef261.pdf","sha256":"d9823224b532485a6f67317da830ce820c3094faf6b3ceaef3c540f024c29bfc","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for filing a claim under the Secure Mind insurance policy and is to be filled by the insured or claimant.","notes":["Please answer all questions fully and correctly; mention 'not applicable' if a question does not apply.","Do not delay returning the form if some particulars are not immediately available; forward them later.","The policy may be voidable if any untrue or incorrect statement or non-disclosure is found.","Attach photocopy of the policy document with the claim form.","Attach original blank cancelled cheque signed by the payee and PAN card copy for EFT payments.","The issue of this form is not an admission of liability.","Use the contact details provided for any doubts or clarifications on the claim form."],"title":"CLAIM FORM FOR SECURE MIND POLICY","submit":{"to":"Secure Mind Claims, ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016.","how":"post","address":"Secure Mind Claims, ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016."},"purpose":"claim","sections":[{"title":"DETAILS OF INSURED","fields":[{"help":"","type":"text","label":"Name of the Insured :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the Insured  :","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Whether Self Employed  / Salaried :","options":["Self Employed","Salaried"],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"CLAIM DETAILS","fields":[{"help":"Tick the relevant insured event","type":"choice","label":"Nature of Insured Event: (Please tick the relevant box)","options":["Death due to accident","Permanent Total Disability due to Accident","Major Medical Illness or Procedure"],"required":null,"pdf_field":""},{"help":"Applicable for death or disability due to accident; enter date in DD/MM/YYYY format","type":"date","label":"Date of Accident :","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause of accident briefly","type":"text","label":"Brief Narration of the Cause of accident :","options":[],"required":null,"pdf_field":""},{"help":"Mention the place where accident occurred","type":"text","label":"Place of accident  :","options":[],"required":null,"pdf_field":""},{"help":"Applicable for major medical illness or surgery; enter date in DD/MM/YYYY format","type":"date","label":"Date of Diagnosis of Major Medical Illness or undergoing of surgery","options":[],"required":null,"pdf_field":""},{"help":"Select the applicable illness or surgery","type":"choice","label":"Please select the type of Major Medical Illness suffered or surgery undergone from the list below","options":["Cancer","End Stage Renal Failure","Major Organ Transplant","Stroke","Paralysis","Heart Valve Replacement Surgery","Multiple Sclerosis","Coronary Artery By Pass Graft Surgery","Heart Attack (Myocardial Infraction)","Benign Brain Tumour","Parkinson's Disease before the age of 50 years","Alzheimer's Disease before the age of 50 years","Surgery of Aorta","Major Burns","Loss of Speech","Deafness","Coma of specified severity","End Stage Liver Disease"],"required":null,"pdf_field":""},{"help":"Enter full name of the treating doctor","type":"text","label":"Name of the treating doctor :","options":[],"required":null,"pdf_field":""},{"help":"Provide phone or other contact details of the doctor","type":"text","label":"Contact details of the treating doctor :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"DECLARATION BY CLAIMANT","fields":[{"help":"","type":"text","label":"Name of Claimant :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence :","options":[],"required":null,"pdf_field":""},{"help":"Enter contact phone number","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature  of Claimant :","options":[],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email Address :","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place :","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"ELECTRONIC FUND TRANSFER (EFT) DETAILS","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Would you like to opt for Electronic Fund Transfer as mode of payment ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name exactly as per bank records","type":"text","label":"Payee Name (as per bank records):","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Payee Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select account type or specify if others","type":"choice","label":"Type of Account: Savings Current Others (specify):","options":["Savings","Current","Others"],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch Name :","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch address","type":"text","label":"Address of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":null,"pdf_field":""},{"help":"Sign to authorize EFT","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"claims under Secure Mind policy including death due to accident, permanent total disability due to accident, and major medical illness or procedure","attachments":["photocopy (Xerox) of the policy document","Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee"],"declarations":["The particulars made by the insured person/claimant in the claim form are true to the best of my/our knowledge and belief.","I authorize ICICI Lombard to seek any medical information from any Medical Practitioner/Hospital or other body who has treated the insured.","I give consent to verify and obtain my identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes.","Statements/information given in this claim form are true, correct and complete.","No material information relevant to claim processing has been withheld or not disclosed.","False or fraudulent statements or suppression of material information will void the policy and claims.","Receipt of claim form or documents does not constitute admission of liability by the Company.","The Company reserves the right to have the insured examined by any doctor for verification.","The details provided for EFT are final and ICICI Lombard is not responsible for cross verification.","RTGS/NEFT facility will be effective within 15 days of receipt of mandate form.","Customer agrees to indemnify ICICI Lombard against claims arising from RTGS/NEFT transactions.","Customer may terminate RTGS/NEFT facility with 15 days prior written notice to ICICI Lombard.","Submission of documents or bank details does not imply admission of liability by the company.","These terms and conditions are governed by laws of India and legal proceedings will be in Mumbai courts.","Customer undertakes to refund any excess amount credited to their account within 7 days of notification.","Claim payment will be credited from date ICICI Lombard receives confirmation from its bankers."],"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/401-claim-form-for-secure-mind-policy"}