{"id":442,"title":"Service Contract Liability Insurance CLAIM FORM","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/service-contract-liabilityl_claim_form-commercial8c0007ff45fd68ff8a0df0055faefcb8.pdf","sha256":"9fe1fd6c8d471ab59e37b95ba95e389634ccd5d90cdd8ea0926294396800547d","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is for filing a claim under the Service Contract Liability Insurance policy and is to be filled by the insured or claimant.","notes":["Details of contract holder and claim details to be furnished in an excel sheet as indicated.","Attach original or self-attested copies of required documents.","Nominee’s bank account details are required in case of a death claim.","Use the bank details exactly as per the provided cheque or passbook.","Submission of documents or bank details does not imply admission of liability.","RTGS/NEFT payment terms and conditions apply as stated in the form."],"title":"Service Contract Liability Insurance CLAIM FORM","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post","address":"ICICI Lombard House 414, Veer Savarkar Marg, Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025"},"purpose":"claim","sections":[{"title":"Part I: Details of Insured and Contract Holder","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter start date of policy period","type":"date","label":"Policy Period: From:","options":[],"required":null,"pdf_field":""},{"help":"Enter end date of policy period","type":"date","label":"To:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Policyholder:","options":[],"required":null,"pdf_field":""},{"help":"To be furnished in an excel sheet","type":"text","label":"Unique Identification no of the Contract:","options":[],"required":null,"pdf_field":""},{"help":"To be furnished in an excel sheet","type":"date","label":"Contract Period: From:","options":[],"required":null,"pdf_field":""},{"help":"To be furnished in an excel sheet","type":"date","label":"To:","options":[],"required":null,"pdf_field":""},{"help":"To be furnished in an excel sheet","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male  Female  Other","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Contact Details:  Mob.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Id:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Part II: Details of Claim","fields":[{"help":"Enter date and time of loss","type":"date","label":"Date and Time of Loss : dd/mm/yy _____________ hrs - min ______","options":[],"required":null,"pdf_field":""},{"help":"Describe location of loss","type":"text","label":"Loss Location :","options":[],"required":null,"pdf_field":""},{"help":"Describe cause or nature of loss","type":"text","label":"Cause / Reason / Nature of loss:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss was reported to police and provide report number","type":"text","label":"Whether loss reported to Police? / Res. No.","options":[],"required":null,"pdf_field":""},{"help":"Provide time of police report","type":"text","label":"If yes, time when the loss was reported to Police-","options":[],"required":null,"pdf_field":""},{"help":"Attach FIR copy if filed","type":"yes-no","label":"Have you filed an FIR? If yes, please attach a copy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide manufacturer or make of product/property","type":"text","label":"Manufacturer / Make :","options":[],"required":null,"pdf_field":""},{"help":"Provide model of product/property","type":"text","label":"Model :","options":[],"required":null,"pdf_field":""},{"help":"Provide unique ID number","type":"text","label":"Unique Identification Number of Product/Property:","options":[],"required":null,"pdf_field":""},{"help":"Describe the incident in detail","type":"text","label":"Detailed description of the incident:","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 PEPs*?","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/claimant"},{"title":"NEFT Details","fields":[{"help":"Enter name as per bank records","type":"text","label":"Claimant /Insured name(as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Claimant /Insured bank account no.:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch name:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank address","type":"text","label":"Address of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code as per cheque leaflet","type":"text","label":"IFSC code no. of the bank:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant/insured"},{"title":"Claimant/Insured Declaration","fields":[{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide OTP","type":"signature","label":"Signature/OTP","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant/insured"}],"deadlines":[],"applies_to":"Service Contract Liability Insurance claims","attachments":["Copy of First Information Report (FIR) if filed","Vouchers or purchase bill, where applicable","Any document evidencing the loss event","Copy of Daily Diary Report (for lost/stolen cases)","Self-attested copy of a valid Identity proof of the claimant/Insured","Cancelled cheque copy or Bank attested copy of Passbook with IFSC code"],"declarations":["The claimant undertakes to refund any excess amount credited in error within 7 days of communication.","Claim payment will be credited after confirmation from the bank and the facility continues unless revoked with 15 days prior notice.","The information provided in the claim form is true, correct and complete.","No material information relevant to claim processing has been withheld or undisclosed.","ICICI Lombard is authorized to collect relevant medical and other information for claim processing.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of claim form or documents does not imply admission of liability by ICICI Lombard.","The policy may be voided for untrue or incorrect statements or non-disclosure of material information.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC."],"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/442-service-contract-liability-insurance-claim-form"}