{"id":412,"title":"CLAIM FORM:  ICICI Lombard Criti Shield Plus","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/icici-lombard-criti-shield-plus8c0007ff45fd68ff8a0df0055f5f68b5.pdf","sha256":"c44fce64c3772d039445a7fa3400bd6f25b16e4da728d54b713d2d546a240143","pages":13,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the ICICI Lombard Criti Shield Plus insurance policy.","notes":["Attach a separate sheet if space is insufficient for details.","Use original bills and documents as specified for each benefit claim.","Claim form issuance is not admission of liability.","For AML compliance, provide PAN, residence proof, photos, cancelled cheque, and NEFT mandate form as applicable.","Submit all hospitalization and treatment documents including indoor case papers, discharge summaries, investigation reports, and certificates.","For death claims, provide death certificate, FIR, post mortem report, and other legal documents as applicable.","Use block letters where applicable.","Only last 4 digits of certain numbers to be entered as specified."],"title":"CLAIM FORM:  ICICI Lombard Criti Shield Plus","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post / in person / e-mail / upload via website","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016; Email: ihealthcare@icicilombard.com; Website: www.icicilombard.com"},"purpose":"claim","sections":[{"title":"PART - I : CUSTOMER RELATED DETAILS","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Policyholder:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Person:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender:","options":["Male","Female","Transgender"],"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":"text","label":"Occupation of Insured","options":[],"required":null,"pdf_field":""},{"help":"Tick if renewal","type":"choice","label":"Is this renewal policy:","options":["No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Mention Old Policy Number( Incase of renewal)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Intimation Service Number:","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 you have other insurance, provide insurer name","type":"text","label":"Name of the insurer","options":[],"required":false,"pdf_field":""},{"help":"If you have other insurance, provide policy/product and plan name","type":"text","label":"Policy /product name & Plan Name","options":[],"required":false,"pdf_field":""},{"help":"If you have other insurance, provide policy number","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If you have other insurance, provide policy period","type":"text","label":"Policy Period","options":[],"required":false,"pdf_field":""},{"help":"If you have other insurance, provide sum insured","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"B. CLAIMANT DETAILS","fields":[{"help":"","type":"text","label":"Name of claimant: (Please ignore if Insured Person is claimant)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship of claimant with Insured Person:","options":[],"required":null,"pdf_field":""},{"help":"Include State, Pin Code, City/Town","type":"text","label":"Address for communication:","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Contact Details: Mob.","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email Id:","options":[],"required":null,"pdf_field":""}],"filled_by":"Claimant (if different from Insured Person)"},{"title":"PART- II: CLAIM DETAILS","fields":[{"help":"Tick the benefits you are claiming for","type":"checkbox","label":"Please tick against each of the Benefit under which you are claiming for, as per the relevant Section and Benefits.","options":["Section A Critical Illness Benefit 1 Comprehensive Critical Illness","Benefit 2 ICU Benefit","Benefit 3 Cancer Restore Benefit","Section B Benefit 4 Major Surgical Procedures","Section C Benefit 5 Accidental Death Benefit","Benefit 6 Permanent Total Disablement (PTD) Benefit","Benefit 7 Permanent Partial Disablement (PPD) Benefit"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Cancer Restore Benefit: Have we paid 100% of Cancer claim earlier:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of diagnosis of major Cancer:","options":[],"required":null,"pdf_field":""},{"help":"Specify organ for initial cancer claim","type":"text","label":"Initial Cancer claim for which organ","options":[],"required":false,"pdf_field":""},{"help":"Specify organ for relapse claim","type":"text","label":"Relapse claim for which organ","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"PART III: Hospital Details if applicable","fields":[{"help":"Provide for each hospital visited","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Provide for each hospital visited","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Specify type of treatment","type":"text","label":"Medical: Surgical :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of treating Medical Practitioner","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nature of Injury/Illness:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"For any Critical Illness, date when the Critical Illness was first diagnosed:","options":[],"required":null,"pdf_field":""},{"help":"Provide time of admission/discharge","type":"text","label":"Time: __________AM/PM","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Number of continuous stay in ICU","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"In case of death: Was any post mortem done:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Reasons for admission:","options":[],"required":null,"pdf_field":""},{"help":"Date and time in DD/MM/YYYY and HH:MM AM/PM format","type":"text","label":"Date and Time of Discharge from ICU","options":[],"required":null,"pdf_field":""},{"help":"Medico Legal Case","type":"yes-no","label":"Was any MLC done:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time in DD/MM/YYYY and HH:MM AM/PM format","type":"text","label":"Date and time of admission in ICU:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Incase of death in ICU please specify date of death:","options":[],"required":false,"pdf_field":""},{"help":"Specify ICU type","type":"text","label":"Type of ICU: CCU/PICU/SICU/NICU/Other please specify:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable reason","type":"checkbox","label":"In case of admission due to Accident:","options":["Medical","Accident","Surgical","Infection"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was your stay in ICU Continuous:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was Insured Person suffering from any Pre-Existing Disease:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Date and time in DD/MM/YYYY and HH:MM AM/PM format","type":"text","label":"Date and time of discharge:","options":[],"required":false,"pdf_field":""},{"help":"Signature from hospital authority","type":"signature","label":"Signature of the Competent authority at treating Hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant/Hospital authorities"},{"title":"PART- IV: NEFT Details","fields":[{"help":"Provide bank address","type":"text","label":"Address of the bank:","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 as per records","type":"text","label":"Name of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Name as per bank account","type":"text","label":"Claimant /Insured Person’s name(as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch name:","options":[],"required":true,"pdf_field":""},{"help":"IFSC code as per cheque leaf","type":"text","label":"IFSC code no. of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Signature of claimant/insured person","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant/Insured Person"},{"title":"PART - V: KYC (KNOW YOUR CUSTOMER)","fields":[{"help":"Mobile or contact number","type":"phone","label":"Mobile/ Contact No.:","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN No.:","options":[],"required":true,"pdf_field":""},{"help":"Policy number","type":"text","label":"Policy Number:","options":[],"required":true,"pdf_field":""},{"help":"Claim number if available","type":"text","label":"Claim Number (if allotted):","options":[],"required":false,"pdf_field":""},{"help":"Aadhar card number","type":"text","label":"Aadhar card:","options":[],"required":true,"pdf_field":""},{"help":"Name of claimant or insured person","type":"text","label":"Claimant/Insured Person's Name: (in respect of whom claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Relation to insured person","type":"text","label":"Relation with the Insured Person:","options":[],"required":false,"pdf_field":""},{"help":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Signature of claimant/insured person","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Attach two passport size photos","type":"photo","label":"Two passport size photos of Insured Person/claimant (stick in the space provided below)","options":[],"required":true,"pdf_field":""},{"help":"Attach one valid ID proof","type":"attachment","label":"One photocopy of proof of identity of Insured Person/claimant (any 1 in the below 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 1 in the below list)","options":["Electricity bill","Ration card","Letter from any recognized public authority","Current statement of bank account","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/Insured Person"},{"title":"Consent letter","fields":[{"help":"Enter policy or proposal number","type":"text","label":"Proposal No. / Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"Name of insured person","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Signature of claimant or insured","type":"signature","label":"Claimant / Insured Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person/claimant"}],"deadlines":[],"applies_to":"Claims under the ICICI Lombard Criti Shield Plus policy for critical illness, major surgical procedures, and personal accident benefits.","attachments":["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","Claim documents as per benefit section (e.g. discharge summary, hospital bills, investigation reports, certificates, FIR, post mortem report, income proof, AML documents, cancelled cheque, NEFT mandate form, etc.)"],"declarations":["The statements/information in the claim form are true, correct and complete.","No material information relevant to claim processing has been withheld or not disclosed.","Authorization to ICICI Lombard to collect medical and other relevant information for claim processing.","False or fraudulent statements or suppression of material information will void the policy and claims.","Receipt of claim form or documents does not imply admission of liability by ICICI Lombard.","Policy may be voided for untrue or incorrect statements or non-disclosure in claim form or related documents.","Consent to verify identity/address through Central KYC Registry or other modes for KYC.","Undertaking to refund any excess amount credited in error within 7 days of notification.","Claim payment will be credited after confirmation from bank; facility continues unless revoked with notice.","Terms and conditions for RTGS/NEFT payments including indemnity and possible charges apply.","Notices may be given by hand, email, website, or post to last known address.","Terms and conditions governed by laws of India with jurisdiction at Mumbai courts."],"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/412-claim-form-icici-lombard-criti-shield-plus"}