{"id":438,"title":"CLAIM FORM PREMISES POLLUTION LIABILITY 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/pollution-premises-liability-commercial.pdf","sha256":"8bf2b10fc3b227bdaaeb21b22ad7dfaa9d972ed235c700eae20e9e47fa1f0193","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and provide details of a claim under the Premises Pollution Liability Insurance policy.","notes":["Attach separate pages if required for claim details.","Use the toll free number 1800 2666 or email customersupport@icicilombard.com for support."],"title":"CLAIM FORM PREMISES POLLUTION LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"End date of the policy period","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retroactively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Sum insured limit under the policy","type":"amount","label":"Limit (sum Insured)","options":[],"required":null,"pdf_field":""},{"help":"Deductible amount applicable","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss-causing event occurred","type":"date","label":"Date of Occurrence of Circumstances leading to loss","options":[],"required":null,"pdf_field":""},{"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":"Describe relationship and position if applicable","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":"Claim Details","fields":[{"help":"Describe the claim in detail","type":"text","label":"Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Specify the jurisdiction where the claim applies","type":"text","label":"Jurisdiction affected","options":[],"required":null,"pdf_field":""},{"help":"Describe the injury or property damage alleged","type":"text","label":"The nature of the alleged bodily Injury and/or property damage","options":[],"required":null,"pdf_field":""},{"help":"Date when the alleged incident occurred","type":"date","label":"The date it was committed","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage alleged","type":"text","label":"The nature of the alleged damage","options":[],"required":null,"pdf_field":""},{"help":"List all claimants involved","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List defendants involved in the claim","type":"text","label":"Defendants","options":[],"required":null,"pdf_field":""},{"help":"Provide an estimate of the claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Provide a timeline of events related to the claim","type":"text","label":"Chronology of Events","options":[],"required":false,"pdf_field":""},{"help":"Current status of any legal proceedings","type":"text","label":"Status of proceedings as on date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place where the form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of the authorised person","type":"signature","label":"Authorised Signatory","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured entity","type":"text","label":"For and on Behalf of","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Premises Pollution Liability Insurance","attachments":["Copy of the legal notice/written intimation received by the Insured","Any legal opinion considered by the Insured","Copy of the complete correspondence till date"],"declarations":["The insured must provide information and cooperation as reasonably required by the insurer.","The insured agrees not to settle or admit liability without the insurer’s prior written consent.","The intimation is without prejudice and insurer’s rights are reserved.","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes."],"dropped_labels":2},"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/438-claim-form-premises-pollution-liability-insurance"}