{"id":428,"title":"Credit Insurance - Financial Institutions NOTIFICATION OF OVERDUE ACCOUNT","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/credit-insurance---financial-institutions.pdf","sha256":"2e52906b8e8c5d2da435e0fb47f2ab00545140175c981dd853dfdb26050b4072","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured (policyholder) to notify ICICI Lombard about overdue accounts related to credit insurance for financial institutions.","notes":["Insured must submit the specified documents together with this notification form.","Intervention fee is payable.","Use the exact invoice and account details as per records."],"title":"Credit Insurance - Financial Institutions NOTIFICATION OF OVERDUE ACCOUNT","submit":{"to":"ICICI LOMBARD General Insurance Co. Ltd.","how":"mail","address":"414, Veer Savarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai – 400025."},"purpose":"claim","sections":[{"title":"Notification Details","fields":[{"help":"Enter the date when this notification is being made","type":"date","label":"Date of Notification:","options":[],"required":null,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the buyer's identification number","type":"text","label":"Buyer No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name and address of the buyer","type":"text","label":"Buyer’s full name and address :-","options":[],"required":null,"pdf_field":""},{"help":"Enter the GST Identification Number of the buyer","type":"text","label":"GSTIN:","options":[],"required":null,"pdf_field":""},{"help":"Enter the contact person's name and telephone number","type":"text","label":"Name of contact person & Tel :-","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name and address of the insured","type":"text","label":"Insured full name and address :-","options":[],"required":null,"pdf_field":""},{"help":"Enter the address where invoices were sent if different from above","type":"text","label":"Address of Invoices (if different from above) :-","options":[],"required":false,"pdf_field":""},{"help":"Enter the name of the entity issuing the invoice if different from above","type":"text","label":"Invoice Issued by (if different from above) :-","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details on Overdues","fields":[{"help":"List invoice reference, invoice date, due date, currency, amount, payments or credit notes (amount, date), and remarks","type":"table","label":"Invoice Ref","options":[],"required":null,"pdf_field":""},{"help":"Enter the net outstanding amount excluding tax or VAT as per statement of account","type":"amount","label":"Net Outstanding Amount (Excluding tax/VAT if any) (As per the Statement Of Account)","options":[],"required":null,"pdf_field":""},{"help":"Select the reason(s) for non-payment; specify if 'Others' is selected","type":"choice","label":"Reasons for Non Payment","options":["Cash Flow problem","Insolvency","Bank transfer delay","Trade Dispute","Others (specify)"],"required":null,"pdf_field":""},{"help":"Provide any other relevant details","type":"text","label":"Other details","options":[],"required":false,"pdf_field":""},{"help":"Describe actions taken to recover the overdue amount","type":"text","label":"Measures taken so far to effect recovery:","options":[],"required":false,"pdf_field":""},{"help":"List any securities held against the debtor","type":"text","label":"Securities held against the debtor:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Payment Terms and Previous Extensions","fields":[{"help":"Enter the usual payment terms in days","type":"number","label":"What is the usual terms of payment given to the buyer?","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you applied for an extension of terms with this buyer previously?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Persons (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 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":"Consent for KYC Verification","fields":[{"help":"Consent to KYC verification is mandatory","type":"checkbox","label":"I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof as well as the identity / address proof of the insured / beneficial owner through Central KYC Registry or UIDAI or through any other modes for the purpose of undertaking KYC","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Signature and Submission","fields":[{"help":"Signature of authorized signatory","type":"signature","label":"Authorized signatory","options":[],"required":true,"pdf_field":""},{"help":"Print name of the signatory","type":"text","label":"Name of signatory:","options":[],"required":true,"pdf_field":""},{"help":"Enter designation of the signatory","type":"text","label":"Designation:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"credit insurance for financial institutions","attachments":["Invoices","Statement of account","Sales contract/purchase order","Bill of Lading / Delivery Receipt"],"declarations":["Insured must declare the full debt exposure on the buyer even for invoices that are not yet due.","Consent is given to the company to verify identity and address proof through Central KYC Registry or 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/428-credit-insurance-financial-institutions-notification-of-overdue-account"}