{"id":402,"title":"Women’s Cancer Shield 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/women-cancer-shield---claim8c0007ff45fd68ff8a0df0055f5f684b.pdf","sha256":"56d63e1bb5b302ceb9e86d9d28f134cf789f3e3b393fa299a7d7bd7f9f8c2f7c","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by the claimant to lodge a claim under the Women’s Cancer Shield insurance policy for cancer-related treatment. The claimant or insured person fills this form.","notes":["Fill the form in CAPITAL LETTERS.","Answer all questions fully and correctly; mention 'not applicable' if a question does not apply.","Only last 4 digits of certain numbers to be entered where specified.","Attach original or self-attested copies of required documents as listed.","Use the contact details provided for claim submission or queries.","The RTGS/NEFT payment facility terms and conditions apply as stated in the form.","Nominee’s bank account details are required in case of death of the insured."],"title":"Women’s Cancer Shield Claim Form","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post or email","address":"Email: ihealthcare@icicilombard.com"},"purpose":"claim","sections":[{"title":"Insurance details","fields":[{"help":"Enter your policy number","type":"text","label":"Policy no","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the policy proposer","type":"text","label":"Name of the proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the insured person","type":"text","label":"Name of the insured person","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of birth of the insured person","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender of insured person","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter 12 digit Aadhaar number","type":"text","label":"Aadhaar card no. of the insured person","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claimant details","fields":[{"help":"Enter claimant's full name","type":"text","label":"Name of the claimant","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to insured","type":"text","label":"Relationship of claimant with the insured person","options":[],"required":null,"pdf_field":""},{"help":"Enter 12 digit Aadhaar number; ignore if insured is claimant","type":"text","label":"Aadhaar card no. of the claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claim communication details","fields":[{"help":"Enter full postal address","type":"text","label":"Address for communication","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile no","options":[],"required":null,"pdf_field":""},{"help":"Enter residential phone number","type":"phone","label":"Res. No","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurer, policy/product name, policy number, policy period, sum insured","type":"table","label":"Do you have any other insurance product with us or any other insurer wherein you have made a claim for the same illness? If yes, please specifiy","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Loan details (if policy linked to loan)","fields":[{"help":"Enter name of financial institution","type":"text","label":"Name of the financial institution","options":[],"required":null,"pdf_field":""},{"help":"Enter Loan Account Number","type":"text","label":"LAN","options":[],"required":null,"pdf_field":""},{"help":"Enter EMI amount","type":"amount","label":"EMI amount","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Other financial instrument details","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Is Policy assigned","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name if policy is assigned","type":"text","label":"If Yes, please name the Financial institution","options":[],"required":null,"pdf_field":""},{"help":"Enter folio number if applicable","type":"text","label":"Folio No. in case of SIP","options":[],"required":null,"pdf_field":""},{"help":"Enter SIP amount if applicable","type":"amount","label":"SIP amount","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claim / Loss details","fields":[{"help":"Enter claim number if already registered","type":"text","label":"Claim no (If claim has already been registered with ICICI Lombard Health Care)","options":[],"required":false,"pdf_field":""},{"help":"Describe the loss","type":"text","label":"Description of loss","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable cancers","type":"checkbox","label":"Please tick against the benefit being claimed for","options":["Breast cancer","Cervical cancer","Other women specific cancer","Ovarian cancer","Fallopian cancer","Vaginal cancer","Cancer of Vulva","Uterine/ endometrial cancer","Thyroid cancer"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date when illness was first diagnosed","options":[],"required":null,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of treating medical practitioner","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Did the insured survive the illness","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank details for claim payment","fields":[{"help":"Enter name as per bank records","type":"text","label":"Claimant/ Insured person’s name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Claimant/ Insured bank account no","options":[],"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 bank","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC code (as mentioned on the cheque leaflet)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"KYC (Know Your Customer)","fields":[{"help":"Enter full name","type":"text","label":"Claimant/Insured Person's Name (in respect of whom claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter claim number if available","type":"text","label":"Claim Number (if allotted)","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile or contact number","type":"phone","label":"Mobile/ Contact No.","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""},{"help":"Paste photos in the space provided","type":"photo","label":"Two passport size photos of Insured Person/claimant","options":[],"required":true,"pdf_field":""},{"help":"Attach one valid identity proof","type":"attachment","label":"One photocopy of proof of identity of Insured Person/claimant (any 1 in the list)","options":["Passport","PAN card","Voter’s Identity card","Driving license","Personal identification and certification of the employees of the insurer","Job card issued by NREGA","Letter from a recognized Public Authority or Public Servant"],"required":true,"pdf_field":""},{"help":"Attach one valid residence proof","type":"attachment","label":"One photocopy of proof of residence of insured person/ claimant (any one in the list)","options":["Electricity bill","Ration card","Letter from any recognized public authority","Current bank statement","Current passbook","Valid lease agreement with rent receipt (not older than 3 months)","Telephone bill (not older than 6 months)","Employer’s certificate as proof of residence"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Consent letter","fields":[{"help":"Enter policy or proposal number","type":"text","label":"Proposal No. / Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Sign the consent letter","type":"signature","label":"Name of the Insured / Claimant / Insured Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Claims under the Women’s Cancer Shield policy for specified women-specific cancers","attachments":["Self-attested copy of a valid Identity proof of the claimant/Insured Person","Cancelled cheque copy or Bank attested copy of Passbook with IFSC code","Two passport size photos of Insured Person/claimant","One photocopy of proof of identity of Insured Person/claimant","One photocopy of proof of residence of insured person/ claimant","Self-attested copy of a valid government-issued identity proof along with the consent letter"],"declarations":["The statements/information provided in the claim form are true, correct and complete.","No material information relevant to claim processing has been withheld or not disclosed.","Authorization is given to ICICI Lombard to collect medical and other relevant information for claim processing.","False or fraudulent statements or concealment of material information will void the policy and claim rights.","Submission of claim form or documents does not imply admission of liability by ICICI Lombard.","The policy may be voided by the insurer for untrue or incorrect statements or non-disclosure.","Consent is given to verify identity through Central KYC Registry or other modes for KYC purposes.","Premiums have been paid from legally acquired sources and will continue to be so paid.","Claim payment will be credited after confirmation from bankers and the RTGS/NEFT terms apply.","The claimant agrees to refund any excess amount credited in error within 7 days of notification."],"dropped_labels":1},"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/402-womens-cancer-shield-claim-form"}