{"id":450,"title":"CYBER SECURE 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/cyber-secure-claim-form-commercial.pdf","sha256":"49d6f61365f105894f43f80dae016118faf440aca83599a6ec153cebbc79a13c","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for insured policyholders to file a claim under the Cyber Secure Insurance policy for losses due to unauthorized transactions or cyber incidents.","notes":["Issuance of this form is not proof of admissibility of liability.","Complete and sign the form fully; use additional sheets if necessary.","Submit the form as per policy wording instructions.","All payments will be made electronically to the insured's bank account as per IRDAI regulations.","The company may condone delay in claim intimation/document submission on merit if delay is beyond insured's control."],"title":"CYBER SECURE INSURANCE CLAIM FORM","submit":{"to":"The Manager, Claims Department, ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025","how":"","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025"},"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 you, provide their details","type":"text","label":"Represented by (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"Enter the amount of loss claimed","type":"amount","label":"Loss Amount","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss incident in detail","type":"text","label":"Brief explanation of loss * (If additional space is needed for explanation attach as a separate document):","options":[],"required":true,"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":false,"pdf_field":""}],"filled_by":"insured policyholder"},{"title":"Details of Bank Account","fields":[{"help":"Name as per bank records","type":"text","label":"Name of Bank Account Holder","options":[],"required":null,"pdf_field":""},{"help":"Your bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Name of your bank","type":"text","label":"Name of Bank","options":[],"required":null,"pdf_field":""},{"help":"9 digit MICR code of your bank branch","type":"number","label":"MICR Code (9 digit)","options":[],"required":false,"pdf_field":""},{"help":"Tick if this is a savings account","type":"checkbox","label":"Saving Account","options":["Saving"],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"11 digit IFSC code of your bank branch","type":"text","label":"IFSC Code (11 digit)","options":[],"required":null,"pdf_field":""},{"help":"Mandatory electronic payment to insured","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 policyholder"}],"deadlines":[],"applies_to":"Cyber Secure Insurance claims","attachments":["Proof of reporting to bank or credit organization","Proof that the bank or credit organization is not indemnifying such loss to You","Complaint letter acknowledged by Police","Copy of Bank Statement","Any other document or other information as necessary to evaluate liability under the policy","KYC documents if claim settlement amount is above INR 1 lakh"],"declarations":["The information given in this claim form is 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.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this form or documents does not guarantee claim acceptance; insurer may require more information.","ICICI Lombard may retain and share information for claims settlement and with government/regulatory authorities.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes."],"dropped_labels":1},"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/450-cyber-secure-insurance-claim-form"}