{"id":443,"title":"CLAIM FORM RETAIL CYBER 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/retail-cyber-liability-retail.pdf","sha256":"bdc71bd5b826debc56ca41b9cad28c074ccbea16a2ff051345ff75180ab82642","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to file a claim under the Retail Cyber Liability Insurance policy with ICICI Lombard General Insurance Company Limited.","notes":["Issuance of this form is not proof of admissibility of liability","Please read the claim form fully before answering","All questions must be answered fully; use additional sheets if necessary","Submit original bills and proofs of payment where applicable","Payments will be made only through electronic mode to the insured's bank account as per IRDAI guidelines","The company may condone delay in claim intimation/document submission on merit if due to reasons beyond insured's control","Delay will not be condoned if claim would have been rejected even if reported in time","For lost wages claim, provide latest salary slip or tax returns as applicable","For unauthorized fund transfer claim, provide proof of reporting to bank, non-indemnification by bank, police complaint, and bank statement","File an FIR if applicable (e.g. third-party property damage, bodily injury, fire)","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting","Assessment and approval of repair/replacement details will be done by Claims Manager/Surveyor","Assessment sheet/survey report turnaround time is 15 days; claim decision within 7 days thereafter"],"title":"CLAIM FORM RETAIL CYBER LIABILITY INSURANCE","submit":{"to":"Claims Department, ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload via website","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai 400025; Email: customersupport@icicilombard.com; Website: https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx"},"purpose":"claim","sections":[{"title":"Customer Information","fields":[{"help":"","type":"text","label":"Name of the policyholder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-Mail Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Website","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Fax Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN card number","type":"text","label":"PAN Card Details","options":[],"required":null,"pdf_field":""},{"help":"If someone is representing the policyholder, provide their name","type":"text","label":"Represented by (if applicable)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Policy Information","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Brief Explanation of Claim","fields":[{"help":"Describe the claim in detail; attach extra sheets if needed","type":"text","label":"BRIEF EXPLANATION OF CLAIM* (If additional space is needed for explanation attach as a separate document)","options":[],"required":true,"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 PEP*?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if you answered Yes above","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""},{"help":"Provide details if any other insurance covers this risk","type":"text","label":"Details of Other Insurance covering same risk","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bank Account","fields":[{"help":"Name as per bank records","type":"text","label":"Name of Bank Account Holder","options":[],"required":true,"pdf_field":""},{"help":"Your bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Name of your bank","type":"text","label":"Name of Bank","options":[],"required":true,"pdf_field":""},{"help":"9 digit MICR code of your bank branch","type":"number","label":"MICR Code (9 digit)","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"11 digit IFSC code for electronic payments","type":"text","label":"IFSC Code (11 digit)","options":[],"required":true,"pdf_field":""},{"help":"Tick if this is a savings account","type":"checkbox","label":"Saving Account","options":["Saving"],"required":false,"pdf_field":""},{"help":"Mandatory as per IRDAI for electronic payment","type":"checkbox","label":"I wish any payment due on the claims will be directly credited to my aforesaid Bank Account.*","options":["Yes"],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["Submit claim form and documents as expressed under the policy wording","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"],"applies_to":"Retail Cyber Liability Insurance claims","attachments":["Proof of Currency paid by You to prevent or end a Cyber Extortion Threat","Identity Theft Costs - copy of invoices/bill and proof of payments made thereto","Crisis Management Costs - copy of invoices/bill and proof of payments made thereto","Cyberbullying Costs - Copy of invoices for costs expended and proof of payments made thereto","Data Restoration Costs - Copy for invoices for costs expended and proof of payments made thereto","Legal fees and expenses - copy of invoices from lawyer for costs expended and proof of payments made thereto","Forensic fees expenses - copy of invoices from digital forensic expert for costs expended and proof of payments made thereto","Consequential losses - copy of bank statements","Any other document or other information as necessary to evaluate liability under the policy","KYC documents for claim settlement amount above 1 lakh","Latest salary slip verified by issuing entity (for lost wages claim)","Latest tax returns (for self-employed lost wages claim)","Proof of reporting to bank or credit organization (for unauthorized fund transfer claim)","Proof that bank or credit organization is not indemnifying such loss","Complaint letter acknowledged by Police","Copy of Bank Statement","Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Documents in support of admissibility of the claim (court proceedings, communications, invoices, payment proofs, investigation reports, counsel opinions, engagement letter)","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for items to be repaired or reinstated","Documents substantiating quantum & value of items under claim not to be 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 initial survey"],"declarations":["The statements/information given in this claim form are true, correct and complete","All persons having an interest in the property are disclosed and no duplicate claim has been made","No material information relevant to the claim has been withheld or not disclosed","False or fraudulent statements or concealment of material information will void the policy and claims","Receipt of claim form or documents does not constitute acceptance of the claim by the company","ICICI Lombard may retain and share information with service providers, promoters or group companies","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC purposes"],"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/443-claim-form-retail-cyber-liability-insurance"}