{"id":440,"title":"CLAIM FORM EMPLOYMENT PRACTICES 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/14-employment-practices-liability-commercial-(007)-27-03-2025.pdf","sha256":"e15a1d5b746519595ee159a9360ae0120b24c48cfc030c840588f50d25a51232","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim under the Employment Practices Liability Insurance policy for losses arising from employment-related claims.","notes":["The insured must provide information and cooperation as reasonably required by the insurer.","No settlement, legal costs, or admission of liability should be made without the insurer's prior written consent.","The intimation is without prejudice and insurer's rights are reserved."],"title":"CLAIM FORM EMPLOYMENT PRACTICES LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai - 400 064."},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Start date of the policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retroactively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Limit Of Liability","options":[],"required":null,"pdf_field":""},{"help":"Amount of loss retained by the insured before insurance applies","type":"amount","label":"Retention","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cyber Liability","options":[],"required":null,"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":"Where the claim event occurred","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Explain the wrongful act alleged","type":"text","label":"The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or incident occurred","type":"date","label":"Date of Loss","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":"Select yes if any applicant is a Politically Exposed Person or related","type":"yes-no","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 of 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":"Additional Claim Information","fields":[{"help":"Provide estimated claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the sequence of events related to the claim","type":"text","label":"Chronology of Events","options":[],"required":null,"pdf_field":""},{"help":"Current status of any legal or claim proceedings","type":"text","label":"Status of proceedings as on date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Indicate if other insurance covers this claim","type":"yes-no","label":"Is there any other insurance that may be applicable to this notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Type of other insurance cover","type":"text","label":"Type of Cover","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Name of insured under other policy","type":"text","label":"Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of other policy period","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Attachments","fields":[{"help":"Attach copy of legal notice or written intimation","type":"attachment","label":"Copy of the legal notice/written intimation received by the Insured","options":[],"required":null,"pdf_field":""},{"help":"Attach any legal opinion obtained","type":"attachment","label":"Any legal opinion considered by the Insured","options":[],"required":false,"pdf_field":""},{"help":"Attach all correspondence related to the claim","type":"attachment","label":"Copy of the complete correspondence till date.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Name of the insured entity","type":"text","label":"For and on Behalf of","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized signatory","type":"signature","label":"Authorised Signatory","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Employment Practices Liability Insurance claims","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 information furnished in this Claim Intimation Form is true, correct and complete to the best of the insured's knowledge.","The insured has not withheld any material information related to the claim.","If any false statement or concealment is made, the right to claim under the policy shall be forfeited.","Consent is given to the insurer to seek necessary information/documents from any third party who has made the claim.","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes."],"dropped_labels":5},"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/440-claim-form-employment-practices-liability-insurance"}