{"id":448,"title":"CLAIM FORM PROFESSIONAL INDEMNITY (TECHNOLOGY) 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/professional-indemnity-(technology)-insurance-commercial.pdf","sha256":"43158f7784c11c2cd3520c66c6fcad78950d10aeb183719e2b63d66ba056cb93","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for the insured to notify and provide details of a claim under the Professional Indemnity (Technology) Insurance policy.","notes":["The insured must not settle or offer to settle any claim or admit liability without the Insurer’s prior written consent","Claim intimation is without prejudice and the Insurer’s rights are reserved","In case of third-party property damage/bodily injury, FIR must be filed if applicable as per policy terms","Claims Manager will appoint a licensed surveyor within 24 hours of reporting the claim","Submit all required documents to the assigned Claims Manager or Surveyor","Use the toll-free number, email or website to register the claim and submit documents","Keep the claim reference number for future correspondence"],"title":"CLAIM FORM PROFESSIONAL INDEMNITY (TECHNOLOGY) INSURANCE","submit":{"to":"the Insurer via toll-free number, email, or website as per claim intimation instructions","how":"post / e-mail / upload via website","address":"Toll-free no.: 1800 2666, Email: customersupport@icicilombard.com, Website: https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx"},"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":"Enter start date of policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Limit Of Liability","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Deductible","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":"Specify where the claim event occurred","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the wrongful act alleged","type":"text","label":"The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss 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":"Provide details if other insurance covers this risk","type":"text","label":"Details of Other/Multiple insurance covering same risk","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 PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answered Yes above","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":"Estimated Amount and Chain of Events","fields":[{"help":"Provide estimated claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Describe events leading to claim in date order","type":"text","label":"Chain of Events (in chronological date wise)","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":""},{"help":"Name of insurer if notified","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Name of insured if notified","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"Policy start date if notified","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Attachments to be submitted","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":null,"pdf_field":""},{"help":"Attach all correspondence related to claim","type":"attachment","label":"Copy of the complete correspondence till date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["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":"Professional Indemnity (Technology) Insurance","attachments":["Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim","FIR / Final Police investigation report wherever applicable","Repair/ replacement quotation, invoice and payment proofs for each item claimed","Documents substantiating the quantum & value of the items under claim","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 which may be specified by the surveyor post completion of initial survey","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","If any untrue or false statement or concealment of material fact is made, the right to claim under the policy shall be forfeited","Consent and authorization is given to the Insurer to seek necessary information/documents from any third party who has made the claim","Consent is given to the Company to verify and obtain identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes"],"dropped_labels":6},"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/448-claim-form-professional-indemnity-technology-insurance"}