{"id":404,"title":"CLAIM FORM FOR LOSS OF JOB INSURANCE","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/20221217008-claim-form-for-loss-of-job-forms-rev-28c0007ff45fd68ff8a0df0055f9a8eaa.pdf","sha256":"fff86a8c532037a49c48ad6121e6821466a7109193c793f07212372092df90c4","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used to claim insurance benefits for loss of job under the Loss of Job Insurance policy. It is filled by the insured person or claimant.","notes":["Attach a separate sheet if space is insufficient for details.","Nominee’s bank account details are required in case of a death claim.","Use self-attested copies for identity proofs.","Cancelled cheque or bank attested passbook copy is required for refund processing.","RTGS/NEFT payment terms and conditions apply as stated in the form.","Claim intimation can be done via toll-free number, email, or website.","Surveyor will be appointed within 24 hours of claim reporting if eligible.","Assessment and claim decision timelines are specified in the form.","Original documents should be submitted as required.","Use block letters where applicable."],"title":"CLAIM FORM FOR LOSS OF JOB INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"You can lodge a claim through the website, phone (toll free 1800 2666), or by visiting nearest branches","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"A. INSURED PERSON DETAILS","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Policy holder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender:","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Contact Details: Mob","options":[],"required":null,"pdf_field":""},{"help":"Residential phone number","type":"phone","label":"Res. No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"12 digit Aadhaar number","type":"text","label":"Aadhaar Card No. of Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"Pan Card","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"B. CLAIMANT DETAILS (PLEASE IGNORE IF INSURED PERSON IS CLAIMANT)","fields":[{"help":"","type":"text","label":"Name of claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship of claimant with Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address for communication","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Contact Details: Mob","options":[],"required":null,"pdf_field":""},{"help":"Residential phone number","type":"phone","label":"Res. No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"12 digit Aadhaar number","type":"text","label":"Aadhaar Card No. of claimant","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"Pan Card","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do You have any other insurance for similar claim (either with Us or with any other insurer) If yes please specify details","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If other insurance exists","type":"text","label":"Name of the insurer","options":[],"required":false,"pdf_field":""},{"help":"If other insurance exists","type":"text","label":"Policy / product name","options":[],"required":false,"pdf_field":""},{"help":"If other insurance exists","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If other insurance exists","type":"text","label":"Policy Period","options":[],"required":false,"pdf_field":""},{"help":"If other insurance exists","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""}],"filled_by":"Claimant"},{"title":"PART – I: Customer related details","fields":[{"help":"PEP means Politically Exposed Person","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":false,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"PART - II: CLAIM DETAILS","fields":[{"help":"If applicable","type":"text","label":"Claim No. (If claim has already been registered with ICICI Lombard)","options":[],"required":false,"pdf_field":""},{"help":"Date when job loss occurred, DD/MM/YYYY","type":"date","label":"Date of Loss","options":[],"required":true,"pdf_field":""},{"help":"Explain reason and details of job loss","type":"text","label":"Description of Loss / Event","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"C. LOAN DETAILS (TO BE FILLED BY INSURED PERSON/ CLAIMANT IF THE POLICY IS LINKED TO AN UNDERLYING LOAN)","fields":[{"help":"","type":"choice","label":"Is the policy assigned:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of bank or financial institution","type":"text","label":"If yes, please mention the name of Financial Institution","options":[],"required":false,"pdf_field":""},{"help":"Loan Account Number","type":"text","label":"LAN No.","options":[],"required":false,"pdf_field":""},{"help":"Monthly EMI amount","type":"amount","label":"EMI amount","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"PART - IV: NEFT DETAILS","fields":[{"help":"Name exactly as in bank records","type":"text","label":"Claimant / Insured Person’s name(as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Claimant / Insured Person’s bank account no.","options":[],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch name","options":[],"required":true,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"IFSC code from cheque leaf","type":"text","label":"IFSC code no. of the bank (should be same as per the provided cheque leaflet)","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person / claimant"}],"deadlines":[],"applies_to":"Loss of Job Insurance claims","attachments":["Duly filled claim form by the Insured Person/claimant","Termination letter and relieving letter from the employer","Any documents stating reason for termination/retrenchment/lay off/permanent dismissal","Appointment letter issued by employer","Last 3 months salary slips","Original Amortization Chart, in case of a loan linked policy","Form-16 from employer","Income Tax Return of the last 3 preceding years","Medical/OPD papers/Discharge papers, where Illness or Injury was the reason for termination (where applicable)","Contact details of Human Resource Personnel - Mobile, Email id, Address and name of employer and HR personnel","Name and contact details (Mobile No, Email ID) of reporting manager","AML Documents - Pan Card Copy, Residence Proof, and 2 passport sized colour photos of Insured Person/claimant","Cancelled cheque and NEFT mandate form - duly filled in by the Insured Person/claimant","Self-attested copy of a valid Identity proof of the claimant/Insured Person","Cancelled cheque copy, Bank attested copy of Passbook with IFSC code - For Refunds, Copy of Passbook with IFSC Code, Account Number, Bank Logo and Account holder Name if cancelled cheque does not contain accountholder name"],"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.","ICICI Lombard is authorized to collect medical and other relevant information from hospitals or institutions for this claim.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of claim form or documents does not imply admission of claim by ICICI Lombard.","The policy may be voided if untrue or incorrect statements or non-disclosure of material information is found.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC purposes."],"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/404-claim-form-for-loss-of-job-insurance"}