{"id":433,"title":"CLAIM FORM FOR CORPORATE COVER II INSURANCE","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/corporate-cover-ii-retail-claim-form.pdf","sha256":"3415187a44a339932fee01cd464579421a81ce854eed654122ca584069c82161","pages":15,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured or claimant to notify and claim loss or damage under the Corporate Cover II Insurance policy issued by ICICI Lombard General Insurance Company Limited.","notes":["Issue of this form is not an admission of liability","In case of third-party property damage/bodily injury, fire etc., file an FIR if applicable","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting","Submit all necessary and relevant documents to assigned CSM/Surveyor","Use separate sheets if required for detailed descriptions","Attach copies of FIR, police reports, repair estimates, and other supporting documents as applicable"],"title":"CLAIM FORM FOR CORPORATE COVER II INSURANCE","submit":{"to":"Assigned Claims Manager (CSM) or Surveyor","how":"Submit claim form and documents via toll-free number, email, website or as instructed by CSM/Surveyor","address":"Email: customersupport@icicilombard.com; Website: https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx"},"purpose":"claim","sections":[{"title":"General Information","fields":[{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter start date of policy period in dd/mm/yy format","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Insured's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number of insured","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Loss Details","fields":[{"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":"Location of loss","type":"text","label":"Address of the premises where the loss occurred","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe incident briefly","type":"text","label":"Brief description of incident","options":[],"required":null,"pdf_field":""},{"help":"Estimated monetary value of loss","type":"amount","label":"Estimated loss amount","options":[],"required":null,"pdf_field":""},{"help":"Provide details if other insurance covers this loss","type":"text","label":"Other insurance on same loss, if yes details","options":[],"required":null,"pdf_field":""},{"help":"Additional relevant information","type":"text","label":"Any other information relevant to processing of claim","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? Yes No","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/claimant"},{"title":"Details of Loss under ICICI Bharat Sookshma Udyam Suraksha cover","fields":[{"help":"Enter time and date of loss","type":"text","label":"Time & Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe affected item","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"Describe occupation","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Yes/No and reasons if No","type":"text","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":[],"required":null,"pdf_field":""},{"help":"Inspection address","type":"text","label":"Address where the loss can be inspected","options":[],"required":null,"pdf_field":""},{"help":"Describe extent of loss","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any additional information relevant to processing of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under Consequential Loss (Fire) Cover","fields":[{"help":"Enter date and time","type":"text","label":"Date and time of Accident","options":[],"required":null,"pdf_field":""},{"help":"Duration of interruption","type":"text","label":"Estimated Interruption period","options":[],"required":null,"pdf_field":""},{"help":"Provide turnover details","type":"text","label":"Turnover for the previous and current Financial year","options":[],"required":null,"pdf_field":""},{"help":"Provide gross profit details","type":"text","label":"Gross profit for the previous and current financial year","options":[],"required":null,"pdf_field":""},{"help":"Provide standing charges","type":"text","label":"Standing charges for the previous and current Financial year","options":[],"required":null,"pdf_field":""},{"help":"Describe affected facility","type":"text","label":"Details of the facility affected","options":[],"required":null,"pdf_field":""},{"help":"Describe alternate facility","type":"text","label":"Any alternate facility used in the interruption period Specify, if any","options":[],"required":false,"pdf_field":""},{"help":"Describe additional costs","type":"text","label":"Any additional costs incurred in the interruption period, Specify, if any","options":[],"required":false,"pdf_field":""},{"help":"Time needed for reinstatement","type":"text","label":"Estimated time required for reinstatement","options":[],"required":null,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any additional information relevant to processing of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under All Risk-Functional Equipment / All Risk-Non Functional items cover","fields":[{"help":"Location of loss","type":"text","label":"Place & address where the loss took place","options":[],"required":null,"pdf_field":""},{"help":"Describe nature of loss","type":"text","label":"Nature of loss/damage","options":[],"required":null,"pdf_field":""},{"help":"Describe property","type":"text","label":"Details of property damaged/lost","options":[],"required":null,"pdf_field":""},{"help":"Estimated value","type":"amount","label":"Estimated value of items lost or Damaged","options":[],"required":null,"pdf_field":""},{"help":"Date/time and attach FIR copy","type":"text","label":"Date and time of reporting the loss to Police Station. (Please furnish copy of FIR)","options":[],"required":null,"pdf_field":""},{"help":"Ownership details","type":"text","label":"Are you the sole owner of the property? If no, provide the details.","options":[],"required":null,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any other information relevant to processing of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under Burglary cover","fields":[{"help":"Occupancy details","type":"text","label":"Were the premises occupied at the time of loss? If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"Suspect details","type":"text","label":"Is anybody suspected of theft? If so state full details","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Insured the sole owner of the (a) The property lost or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Owner details","type":"text","label":"(b) If no, the property belongs to whom?","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"(c) Is the insured responsible for repairs to the premises?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List contents lost","type":"text","label":"Value and description of contents lost (Attach separate sheet)","options":[],"required":null,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any other information relevant to processing to claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under Public Liability/ Employer’s Liability/ Personal Accident/ Tenants Legal Liability cover","fields":[{"help":"Age and gender","type":"text","label":"Age and sex","options":[],"required":null,"pdf_field":""},{"help":"Address of injured person","type":"text","label":"Resident Address","options":[],"required":null,"pdf_field":""},{"help":"Occupation details","type":"text","label":"What is the occupation in which the injured person is employed?","options":[],"required":null,"pdf_field":""},{"help":"Work details at time of accident","type":"text","label":"Was the injured person engaged in this occupation when the accident occurred? If not, state fully the nature of the work he was doing at the time of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Employment and salary details","type":"text","label":"Is the injured person in your direct employment? If yes provide the wages, bonus and other allowances payable per annum to the employee","options":[],"required":null,"pdf_field":""},{"help":"Describe injury","type":"text","label":"Give a brief description of injury?","options":[],"required":null,"pdf_field":""},{"help":"Disability percentage and attach certificate","type":"text","label":"What is the % of disability if any? Attach a Certificate of a Doctor confirming disability?","options":[],"required":null,"pdf_field":""},{"help":"Expected disablement duration","type":"text","label":"What is the probable period of the disablement","options":[],"required":null,"pdf_field":""},{"help":"Hospital details","type":"text","label":"Has the injured person been removed to Hospital or medically attended? If yes, give name and address of Hospital attending to injured person?","options":[],"required":null,"pdf_field":""},{"help":"Admission date","type":"date","label":"Date of admission in hospital","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has any case been filed in any court of Law/tribunal against you, in relation to the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date/time and attach documents","type":"text","label":"Date and time of receipt of Notice/Summons from the Authorities. Attach all documents received with the Notice from the court.","options":[],"required":null,"pdf_field":""},{"help":"Legal advice details","type":"text","label":"Does the insured propose to/has already availed of, any legal advise. If yes, details of the lawyer/law firm together with their opinion.","options":[],"required":false,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any other information relevant to processing of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under Mediclaim cover","fields":[{"help":"Name of insured employee","type":"text","label":"Name of the insured Employee","options":[],"required":null,"pdf_field":""},{"help":"Employee salary roll number","type":"text","label":"Salary Roll No.","options":[],"required":null,"pdf_field":""},{"help":"Policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Name and relationship if family member","type":"text","label":"Details of the insured person in respect of whom claims is made: If family member, name & relationship to the insured","options":[],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"Present completed age","options":[],"required":null,"pdf_field":""},{"help":"Occupation of insured person","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Address of insured person","type":"text","label":"Resident Address","options":[],"required":null,"pdf_field":""},{"help":"Describe illness or injury","type":"text","label":"Nature of disease/ illness contracted or injury suffered","options":[],"required":null,"pdf_field":""},{"help":"Date in dd/mm/yy format","type":"date","label":"Date of injury sustained or diseases/illness first detected","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name and address","type":"text","label":"Name and address of the attending medical practitioner","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"Registration number of the Hospital/Nursing Homes/Clinic","options":[],"required":null,"pdf_field":""},{"help":"Admission date","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Discharge date","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Details of hospitalization expenses","type":"text","label":"State whether pre or post Hospitalization expenses are incurred. If yes, please give details of such expenses.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"yes-no","label":"Was the injured person in respect of whom claims being made absent from work? If so, please furnish the details of such absence Yes/No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"employee/insured"},{"title":"Declarations and Consent","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under Glass Breakage cover","fields":[{"help":"Provide total value and attach description","type":"amount","label":"Total value of loss/damage(description to be enclosed in the separate sheet)","options":[],"required":null,"pdf_field":""},{"help":"State repairability and attach estimate","type":"text","label":"Whether the breakdown/ damage is repairable/total loss? Attach the estimate of repairs","options":[],"required":null,"pdf_field":""},{"help":"Premises status and vacancy period","type":"text","label":"Whether the premises was under construction/occupied or vacant, if vacant period of vacancy","options":[],"required":null,"pdf_field":""},{"help":"Select type of glass","type":"choice","label":"Describe the nature of glass Plain / Embossed / Silvered / Ornamental / Any other","options":["Plain","Embossed","Silvered","Ornamental","Any other"],"required":null,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any other information relevant to claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Loss under Cash in Safe or Cash in Transit or Fidelity or Cheque Forgery cover","fields":[{"help":"Select where loss occurred","type":"choice","label":"Did the loss occur when the money was kept in safe or whilst in transit?","options":["Safe","In Transit"],"required":null,"pdf_field":""},{"help":"Safe location details","type":"text","label":"If in Safe Name of the location(s) and details","options":[],"required":null,"pdf_field":""},{"help":"Custodian of safe keys","type":"text","label":"In whose custody were the Safe keys?","options":[],"required":null,"pdf_field":""},{"help":"Amount in safe","type":"amount","label":"Total amount of money in safe at time of loss","options":[],"required":null,"pdf_field":""},{"help":"Date and time of discovery","type":"text","label":"If in Transit: Date and Time when loss was discovered.","options":[],"required":null,"pdf_field":""},{"help":"Transit route","type":"text","label":"Places between which money was in transit.","options":[],"required":null,"pdf_field":""},{"help":"Describe loss circumstances","type":"text","label":"How & where did the loss occur?","options":[],"required":null,"pdf_field":""},{"help":"Amount carried during transit","type":"amount","label":"What was the amount carried?","options":[],"required":null,"pdf_field":""},{"help":"Amount forged","type":"amount","label":"Amount of money forged","options":[],"required":null,"pdf_field":""},{"help":"Suspect details","type":"text","label":"Is anybody suspected of fraud","options":[],"required":null,"pdf_field":""},{"help":"Describe forgery","type":"text","label":"Brief description of forgery","options":[],"required":null,"pdf_field":""},{"help":"Additional info","type":"text","label":"Any other information relevant of claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"}],"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 (except for policies on reinstatement value basis)"],"applies_to":"Corporate Cover II Insurance policy claims","attachments":["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 each item claimed","Documents substantiating the 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 completion of initial survey","Copy of FIR for police reported losses","Certificate of a Doctor confirming disability (if applicable)","Estimate of repairs for glass breakage","Documents received with court Notice/Summons (if applicable)"],"declarations":["The particulars made by the injured person in the claim form are true to the best of our knowledge and belief","Consent is given to the Company to verify and obtain identity/address proof through Central KYC Registry or 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/433-claim-form-for-corporate-cover-ii-insurance"}