{"id":446,"title":"CLAIM FORM PRODUCT RECALL GUARANTEE AND FINANCIAL LOSS 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/product-recall-guarantee-and-financial-loss-liability-commercial.pdf","sha256":"4094abf0a5749439695816dba14ae6219b6e7c00036fea59725d5ea61444ba68","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the insured to notify and claim under the Product Recall Guarantee and Financial Loss Liability insurance policy. The insured must provide details of the claim and cooperate with the insurer.","notes":["The insured must not settle or offer to settle any claim, incur defence costs or admit liability without the insurer's prior written consent.","The intimation is without prejudice and insurer’s rights are reserved."],"title":"CLAIM FORM PRODUCT RECALL GUARANTEE AND FINANCIAL LOSS LIABILITY INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of Cover:","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":"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":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Date when the incident leading to loss occurred","type":"date","label":"Date of Occurrence of Circumstances leading to loss","options":[],"required":null,"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":null,"pdf_field":""},{"help":"Provide details if answer to previous question is Yes","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""},{"help":"Describe the claim in detail","type":"text","label":"Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Specify the jurisdiction affected by the claim","type":"text","label":"Jurisdiction affected","options":[],"required":null,"pdf_field":""},{"help":"Describe the alleged injury or property damage","type":"text","label":"The nature of the alleged bodily Injury and/or property damage","options":[],"required":null,"pdf_field":""},{"help":"Date when the alleged injury or damage occurred","type":"date","label":"The date it was committed,","options":[],"required":null,"pdf_field":""},{"help":"Describe the alleged damage","type":"text","label":"The nature of the alleged damage,","options":[],"required":null,"pdf_field":""},{"help":"List the names of claimants","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List the defendants involved","type":"text","label":"Defendants","options":[],"required":null,"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":"Place where the form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized signatory","type":"signature","label":"Authorised Signatory","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Product Recall Guarantee and Financial Loss 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.","No material information has been withheld.","If any untrue or false statement is made or material fact concealed, the right to claim under the policy shall be forfeited.","The insured consents to the insurer seeking 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":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/446-claim-form-product-recall-guarantee-and-financial-loss-liability-insurance"}