{"id":462,"title":"CLAIM FORM EMPLOYEE DISHONESTY LIABILITY INSURANCE POLICY","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/employee-dishonesty-liability-retail.pdf","sha256":"f11bdd93f1a20192a4e38e563fe32927a6b1df1068033f9c55c44715d5d87a45","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim under the Employee Dishonesty Liability Insurance policy for losses discovered during the policy period.","notes":["Intimation is without prejudice and insurer's rights are reserved","Attach separate pages if required for description of loss","File an FIR if applicable as per policy terms and conditions","Claims Manager will appoint a licensed surveyor within 24 hours of reporting the claim","Submit all required documents to the assigned Claims Service Manager or Surveyor","Use the claim reference number for future correspondence"],"title":"CLAIM FORM EMPLOYEE DISHONESTY LIABILITY INSURANCE POLICY","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload via website or as instructed by Claims Manager","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhivinayak Temple, Prabhadevi, Mumbai - 400 064; 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":"Enter your policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Start date of the policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Enter the limit of liability under the policy","type":"amount","label":"Limit Of Liability","options":[],"required":null,"pdf_field":""},{"help":"Enter the deductible amount applicable","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Describe the loss in detail; attach separate pages if required","type":"text","label":"Description of the Loss","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured entity","type":"text","label":"Name of Entity","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss was discovered","type":"date","label":"Date of Discovery","options":[],"required":null,"pdf_field":""},{"help":"Explain how the loss was discovered","type":"text","label":"Circumstances leading to discovery of Loss","options":[],"required":null,"pdf_field":""},{"help":"Provide an estimated amount of the loss","type":"amount","label":"Estimated Quantum of 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 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"},{"title":"Other Insurance Details","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Is there any other insurance that may be applicable to this notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Type of other insurance cover","type":"text","label":"Type of Cover:","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Name of insured under other insurance","type":"text","label":"Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Name of the insured or authorized signatory","type":"text","label":"For and on Behalf of","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized person","type":"signature","label":"Authorised Signatory","options":[],"required":null,"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":"Employee Dishonesty Liability Insurance","attachments":["Professional opinion & Investigation report taken by the insured","Loss Calculation","Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Documents in support of admissibility of the claim (court proceedings, communications, invoices, payment proofs, investigation reports, counsel opinion, engagement letter)","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for items to be repaired or reinstated","Documents substantiating the quantum & value of items under claim not to be repaired or reinstated","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 specified by the surveyor post completion of initial survey"],"declarations":["The information furnished in this Claim Intimation Form is true, correct and complete to the best of the insured's knowledge","Any untrue or false statement or concealment of material fact will forfeit the right to claim under the policy","Consent is given to the insurer to seek necessary information/documents from any third party who has made a claim against the insured","Consent is given to the insurer to verify and obtain 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/462-claim-form-employee-dishonesty-liability-insurance-policy"}