{"id":414,"title":"CLAIM FORM FOR ICICI BHARAT LAGHU UDYAM SURAKSHA Notification of Physical Loss or Damage","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/claim-form-for-icici-bharat-laghu-udyam-suraksha.pdf","sha256":"8f36851fe532236de4f7cec6b6e56ae8a1e5f05fa753b094f484c7694f9cf348","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to notify and claim for physical loss or damage under the ICICI Bharat Laghu Udyam Suraksha insurance policy.","notes":["Issue of this form is not an admission of liability.","If insurance is effected with other companies, copies of such policies must be attached.","In case of third-party property damage or bodily injury, FIR must be filed as per policy terms.","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting.","Assessment sheet or survey report will be furnished within 15 days of receipt of claim form and documents.","Claim decision will be made within 7 days of receipt of assessment sheet or survey report, except for reinstatement value policies.","All claims must be based on actual value of goods at time of loss, excluding any profit.","Use original documents and provide clear photographs or videos of damaged property."],"title":"CLAIM FORM FOR ICICI BHARAT LAGHU UDYAM SURAKSHA Notification of Physical Loss or Damage","submit":{"to":"assigned Claims Service Manager (CSM) or Surveyor","how":"submit documents to assigned CSM/Surveyor as instructed","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid phone number","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"If applicable, provide details of mortgagee or other interested parties","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Other Insurance","fields":[{"help":"If insured with other companies, provide insurer name","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide policy number(s) of other insurance","type":"text","label":"Policy No. (s).","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policies","type":"amount","label":"Sum Insured Rs.","options":[],"required":null,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Loss","fields":[{"help":"Provide exact time and date when loss occurred","type":"date","label":"Time & Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss (e.g. fire, theft)","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the affected insured items","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Inspection and Extent","fields":[{"help":"Provide location address for surveyor inspection","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe the extent of damage or loss","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant details for claim processing","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Person (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 close relative of a PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answer above 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":"Fire Claim Details of Property Destroyed or Damaged","fields":[{"help":"Description of the damaged property or item","type":"text","label":"Description of affected","options":[],"required":null,"pdf_field":""},{"help":"Any deductions applicable","type":"text","label":"Deduction for","options":[],"required":null,"pdf_field":""},{"help":"Net value after deductions","type":"amount","label":"Value of Net","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Physical loss or damage claims under ICICI Bharat Laghu Udyam Suraksha policy","attachments":["Copies of other insurance policies if applicable","Claim bill / Claim Form duly filled up","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","FIR / 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 not to be 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 provided in this claim form is true, correct and complete.","All persons having interest in the property are disclosed as per policy or endorsements.","No other claim for the same loss has been made with any other insurer except as disclosed.","No material information relevant to the claim has been withheld or concealed.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this form or documents does not constitute admission of liability by the insurer.","Consent is given to verify identity and address proofs through Central KYC Registry, UIDAI or other modes for KYC purposes."],"dropped_labels":6},"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/414-claim-form-for-icici-bharat-laghu-udyam-suraksha-notification-of-physical-loss-o"}