{"id":420,"title":"CLAIM FORM ERECTION ALL RISK INSURANCE 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-erection-all-risk-insurance-commercial.pdf","sha256":"08c983d6130e22b783754077892c89f3a92b92490e5a681e755bcea9cceb3158","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage under Erection All Risk Insurance policies.","notes":["The issuance of this form is not to be taken as an Admission of Liability.","Please answer all questions fully.","Attach original blank cancelled cheque signed by the payee and PAN card copy for fund transfer.","Terms and conditions for payments through RTGS/NEFT are provided and must be acknowledged."],"title":"CLAIM FORM ERECTION ALL RISK INSURANCE Notification of Physical Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"i) Name","options":[],"required":null,"pdf_field":""},{"help":"Address where correspondence can be sent","type":"text","label":"ii) Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the insured","type":"phone","label":"iii) Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Loss or Damage","fields":[{"help":"Date and time of loss or damage","type":"date","label":"2. When did the loss or damage occur? (State date and time)","options":[],"required":null,"pdf_field":""},{"help":"Location of the insured property","type":"text","label":"3. The address where the property (item) covered is situated.","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage to the insured erection property","type":"text","label":"4. Particulars of damage to erection property.","options":[],"required":null,"pdf_field":""},{"help":"Describe damage to any third party property","type":"text","label":"5. a) Nature & extent of damage, if any, belonging to third party.","options":[],"required":null,"pdf_field":""},{"help":"Explain cause and circumstances of damage","type":"text","label":"6. What was the cause of the damage and how did it occur? (eg. Defective material, faulty design, mention particulars of parts)","options":[],"required":null,"pdf_field":""},{"help":"Indicate if damage happened during testing","type":"yes-no","label":"7. a) Has damage occurred during testing?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of any witness to the damage event","type":"text","label":"8. Give name & address of the witness to the occurrence.","options":[],"required":null,"pdf_field":""},{"help":"State if any party is responsible for the damage","type":"text","label":"9. a) Is any one responsible for damage?","options":[],"required":null,"pdf_field":""},{"help":"Location for inspection of damaged items","type":"text","label":"10. Address where the damaged items can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Estimated financial loss or damage amount","type":"amount","label":"11. What is the estimated amount of loss or damage?","options":[],"required":null,"pdf_field":""},{"help":"Details of repair method and parts replacement","type":"text","label":"12. How will the damages be repaired?(state the details whether any parts must be replaced)","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of how damage happened","type":"text","label":"13. How did the damage occur? (This question must be answered in detail)","options":[],"required":null,"pdf_field":""},{"help":"Estimated salvage or scrap value of damaged parts","type":"amount","label":"14. The estimate salvage or scrap value of damaged parts to be replaced.","options":[],"required":null,"pdf_field":""},{"help":"Information on other insurance coverage for this loss","type":"text","label":"15. Details of any other insurance under which you are entitled to recover in respect of the loss or damage.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you will do repairs yourself","type":"yes-no","label":"16. Do you wish to carry out repairs yourself?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Repairer details if repairs are entrusted","type":"text","label":"17. Name & address of the repairer, if entrusted for repairs.","options":[],"required":null,"pdf_field":""},{"help":"Any other relevant information for claim processing","type":"text","label":"18. Any additional information relevant to processing of claim:","options":[],"required":false,"pdf_field":""},{"help":"Declare if you or related persons are Politically Exposed Persons","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":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Signature","fields":[{"help":"Place 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":"Signature of the insured claimant","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Signature of the bank account holder for payment","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Erection All Risk Insurance claims","attachments":["Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having interest in the property are disclosed as per the proposal or policy endorsement.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this claim form or documents does not imply admission of liability by the company.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes."],"dropped_labels":3},"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/420-claim-form-erection-all-risk-insurance-notification-of-physical-loss-or-damage"}