{"id":444,"title":"CLAIM FORM REPRESENTATIONS AND WARRANTIES 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/representation-and-warranty-insurance-commercial.pdf","sha256":"de06d4d82a91d837eefbad344cf8a2df0939b476997ee90ff94436faf2c15282","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the insured to notify and provide information to the insurer about a claim under the Representations and Warranties Insurance policy.","notes":["The insured must not settle or offer to settle any claim, incur costs, assume contractual obligations or admit liability without the insurer's prior written consent.","The intimation is without prejudice and the insurer's rights are reserved.","Attach separate pages if more space is required for the chain of events."],"title":"CLAIM FORM REPRESENTATIONS AND WARRANTIES INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the circumstances causing the loss occurred","type":"date","label":"Date of Occurrence of Circumstances leading to loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the breach that led to the claim","type":"text","label":"Description of the Breach","options":[],"required":null,"pdf_field":""},{"help":"Explain the nature of the alleged breach","type":"text","label":"The nature of the alleged breach","options":[],"required":null,"pdf_field":""},{"help":"List the names of all claimants","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"Provide the estimated claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the current status of any legal or claim proceedings","type":"text","label":"Status of proceedings as on date:","options":[],"required":null,"pdf_field":""},{"help":"List the events in chronological order; attach separate pages if required","type":"text","label":"Chain of Events (in chronological date wise)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Select Yes or No","type":"choice","label":"Is there any other insurance that may be applicable to this notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, specify the type of cover","type":"text","label":"Type of Cover:","options":[],"required":null,"pdf_field":""},{"help":"Name the other insurer","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Name the insured under the other policy","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"Start date of the other policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Person (PEP) Declaration","fields":[{"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":"Provide details if applicable","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Enter the place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the authorised signatory","type":"signature","label":"Authorised Signatory","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","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 and belief.","The insured has not withheld any information material to this claim.","If any untrue or false statement is made or material fact is concealed, the right to claim under the policy shall be forfeited.","The insured consents and authorizes the insurer to seek necessary information/documents from any third party who has made the claim.","The insured consents to the insurer verifying identity/address proof through Central KYC Registry, UIDAI or other modes for KYC purposes."],"dropped_labels":3},"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/444-claim-form-representations-and-warranties-insurance"}