{"id":454,"title":"CLAIM FORM FOR MEGA RISK 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/claim-form-for-mega-risk-insurance-commercial.pdf","sha256":"07bd377c3d76d11e5b31ee2399566b5cf324831a710bc8354e2ca1206a667906","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for notifying physical loss or damage under the Mega Risk Insurance policy and is filled by the insured claimant.","notes":["The issue of this form is not to be taken as an admission of liability.","All claims must be based upon the actual value of the goods at the time of fire, excluding any profit.","Politically Exposed Persons (PEPs) are defined as individuals entrusted with prominent public functions by a foreign country.","Use the exact policy item numbers and descriptions for property affected.","Attach copies of other insurance policies if applicable."],"title":"CLAIM FORM FOR MEGA RISK INSURANCE","submit":{"to":"","how":"","address":"Mailing Address: Interface Building No.16, 601/602, 6th Floor, New Link Road Malad (W), Mumbai - 400 064."},"purpose":"claim","sections":[{"title":"DETAILS OF INSURED","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":false,"pdf_field":""},{"help":"Policy number of your Mega Risk Insurance","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured claimant"},{"title":"DETAILS OF OTHER INSURANCE","fields":[{"help":"If you have insurance with other companies, provide their details","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No. (s).","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured Rs.","options":[],"required":false,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Period From","options":[],"required":false,"pdf_field":""},{"help":"End date of other insurance policy","type":"date","label":"To","options":[],"required":false,"pdf_field":""}],"filled_by":"insured claimant"},{"title":"DETAILS OF LOSS","fields":[{"help":"Provide exact time and date when the loss occurred","type":"date","label":"Time & Date of Fire / Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe the cause of the fire or loss","type":"text","label":"Cause of Fire / Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe the affected insured items","type":"text","label":"Item of Policy affected (give description)","options":[],"required":true,"pdf_field":""},{"help":"State the use or occupation of the premises when loss occurred","type":"text","label":"Occupation of the premises at the time of Fire / Loss","options":[],"required":true,"pdf_field":""},{"help":"Indicate if the fire brigade was informed; if no, explain why","type":"yes-no","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide the location address for inspection of loss","type":"text","label":"Address where the loss can be inspected.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured claimant"},{"title":"EXTENT OF LOSS","fields":[{"help":"Describe the extent of the loss in detail","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured claimant"},{"title":"ADDITIONAL INFORMATION","fields":[{"help":"Provide any other relevant details for claim processing","type":"text","label":"Any additional information relevant to processing of Claim.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No regarding Politically Exposed Person status","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member / Close relatives / Associates close relative of a PEP*?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe relationship and position if answer above is Yes","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured claimant"},{"title":"FIRE CLAIM FORM - DETAILS OF CLAIM FOR PROPERTY DESTROYED OR DAMAGED","fields":[{"help":"Policy item number of the affected property","type":"text","label":"Item No. of Policy","options":[],"required":true,"pdf_field":""},{"help":"Describe the property damaged or destroyed","type":"text","label":"Description of affected Property","options":[],"required":true,"pdf_field":""},{"help":"Value of the property at the time of fire","type":"amount","label":"Value at the time of Fire Rs.","options":[],"required":true,"pdf_field":""},{"help":"Value of any salvage recovered","type":"amount","label":"Deduction for Value of Salvage Rs.","options":[],"required":true,"pdf_field":""},{"help":"Net claim amount after salvage deduction","type":"amount","label":"Net Amount Claimed Rs.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured claimant"},{"title":"DECLARATION AND SIGNATURE","fields":[{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Mega Risk Insurance","attachments":["copies of other insurance policies if insurance is effected with other companies"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal form or policy endorsements.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this claim form or documents does not constitute admission of liability by the company.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC."],"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/454-claim-form-for-mega-risk-insurance"}