{"id":410,"title":"CLAIM FORM FOR Extended Warranty Insurance Notification of lost or stolen Asset","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/extended-warranty-lost-and-stolen-assests-retail-claim-form.pdf","sha256":"67d4827b0c9ee1ae382035dd7c3d63ca8a8e8a8bc8c933b51e7c980eaccbd252","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is for notifying and claiming loss or theft of assets covered under Extended Warranty Insurance. It is filled by the insured policyholder.","notes":["The issue of this form is not an admission of liability","Register the claim via toll-free number, email or website to receive claim reference number","File an FIR if applicable especially for third-party property damage or bodily injury","A licensed surveyor will be appointed within 24 hours of claim reporting","Submit all documents to the assigned Claims Manager or Surveyor","Use original bills and documents as specified","The turnaround time for claim assessment and decision is specified","The form is to be signed and dated by the insured"],"title":"CLAIM FORM FOR Extended Warranty Insurance Notification of lost or stolen Asset","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"ICICI Lombard House 414, Veer Savarkar Marg, Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025; Email: customersupport@icicilombard.com"},"purpose":"claim","sections":[{"title":"Policy and Loss Details","fields":[{"help":"Enter your policy or cover note number","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy period","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the loss occurred","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"If available, enter the claim number","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the cover period start and end dates","type":"text","label":"Cover Period : From _________To ___________","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid contact phone number","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email Address","options":[],"required":null,"pdf_field":""},{"help":"Enter date (dd/mm/yy) and time (hrs-min) of loss","type":"date","label":"Date and Time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Enter date (dd/mm/yy) and time (hrs-min) when loss was discovered","type":"date","label":"Date and Time of Discovery","options":[],"required":null,"pdf_field":""},{"help":"Enter the location and address where the loss occurred","type":"text","label":"Place & address of loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause or nature of the loss","type":"text","label":"Cause / Reason / Nature of loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if the loss was reported to police (Yes/No)","type":"text","label":"Whether loss reported to Police?","options":[],"required":null,"pdf_field":""},{"help":"Enter time when loss was reported to police if applicable","type":"text","label":"If yes, time when the loss was reported to Police","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Asset and Incident Details","fields":[{"help":"Indicate if FIR was filed and attach copy if yes","type":"yes-no","label":"Have you filed an FIR? If Yes, please attach a copy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the manufacturer of the asset","type":"text","label":"Manufacturer","options":[],"required":null,"pdf_field":""},{"help":"Enter the model of the asset","type":"text","label":"Model","options":[],"required":null,"pdf_field":""},{"help":"Enter the unique identification number of the asset","type":"text","label":"Unique Identification Number","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description of how the incident occurred","type":"text","label":"Detailed description of the incident","options":[],"required":null,"pdf_field":""},{"help":"Provide details if other insurance covers the same risk","type":"text","label":"Details of Other Insurance covering same risk","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"PEP Declaration","fields":[{"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 PEPs*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answer to previous question is Yes","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":"Declaration and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["Assessment sheet / Survey report will be furnished within 15 days of receipt of claim form and documents","Claim will be decided within 7 days of receipt of the assessment sheet / survey report"],"applies_to":"Extended Warranty Insurance claims for lost or stolen assets","attachments":["FIR copy if filed","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim (e.g. Service Engineer’s Report, Fire Brigade Report)","Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for items to be repaired or reinstated","Documents substantiating quantum & value of items under claim if not repaired or reinstated","Offer for retention of salvage, if any","KYC / NEFT Details as per AML guidelines","Invoice copy / Goods Receipt Note / Monetary Claim on carrier / Damage Certificate","Any other document specified by the surveyor post initial survey"],"declarations":["The information given in this claim form is true, correct and complete","The articles described belong to the person named and no other person has interest","Details of persons having interest in the property are as per proposal form or policy endorsement","No similar claim has been made with any other insurance company except as disclosed","No material information relevant to claim processing has been withheld or undisclosed","False or fraudulent statements or concealment of information will void the policy and claims","If the property is recovered, the insured will refund any amount advanced by the company","Receipt of claim form or documents does not constitute admission of claim by the company","Consent is given to verify identity/address proof 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/410-claim-form-for-extended-warranty-insurance-notification-of-lost-or-stolen-asset"}