{"id":463,"title":"CLAIM SETTLEMENT FORM OF PROFESSIONAL INDEMNITY POLICY FOR MEDICAL ESTABLISHMENTS","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-for-medical-establishments-retail.pdf","sha256":"b1b5c5097919d469511377557f53fa647ae29895b0351acdca9c3ff6beb0757f","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is for medical establishments insured under the Professional Indemnity Policy to report incidents and submit claims related to professional indemnity. It is filled by the insured medical establishment.","notes":["The issue of this form is not to be taken as an admission of liability.","Insured shall not enter into compromise/settlement without written permission of the Company.","Attach separate sheets if space is insufficient for details.","In case of third-party property damage/bodily injury, file an FIR if applicable as per policy terms.","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting.","Submit all relevant documents to the assigned Claims Manager or Surveyor.","Use original documents and provide clear photographs/videos where applicable.","Keep claim reference number for future correspondence.","Provide KYC/NEFT details as per AML guidelines."],"title":"CLAIM SETTLEMENT FORM OF PROFESSIONAL INDEMNITY POLICY FOR MEDICAL ESTABLISHMENTS","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation/Profession of Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number with country/area code","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Person as defined","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":"Describe relationship and position","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":"Details of Claimant","fields":[{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Claimant's full address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Claimant's phone number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Describe the professional service given","type":"text","label":"Mention the type of professional service provided to the Claimant in detail","options":[],"required":null,"pdf_field":""},{"help":"Date of service","type":"date","label":"When was the service provided to Claimant","options":[],"required":null,"pdf_field":""},{"help":"Role or capacity of claimant","type":"text","label":"Please specify the capacity in which the claimant is making/can make the claim against you","options":[],"required":null,"pdf_field":""},{"help":"Date and manner of first knowledge","type":"text","label":"When and how did you first come to know of the error/omission","options":[],"required":null,"pdf_field":""},{"help":"Describe the incident briefly","type":"text","label":"Brief description of the incident which can lead to claim","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance policies if applicable","type":"text","label":"Give particulars of any other insurance, if any in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Alleged Claim","fields":[{"help":"Date and time when alleged error occurred","type":"date","label":"Alleged Date & Time of Error/Omission/negligence","options":[],"required":null,"pdf_field":""},{"help":"Name of alleged person","type":"text","label":"Name of the person who has been alleged for Error/Omission","options":[],"required":null,"pdf_field":""},{"help":"Designation of alleged person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Qualification of alleged person","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Describe the event briefly","type":"text","label":"Brief description of the event","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claimant (continued)","fields":[{"help":"Provide claimant details; attach extra sheet if needed","type":"text","label":"Give name/es, address/es occupation/s of Claimant (Attach separate sheet, if space not sufficient )","options":[],"required":null,"pdf_field":""},{"help":"Describe injury or loss; attach extra sheet if needed","type":"text","label":"Details of Injury/death/damage/loss to the claimant (Attach separate sheet, if space not sufficient )","options":[],"required":null,"pdf_field":""},{"help":"Number of persons affected","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Role of claimant and attach complaint/notice","type":"text","label":"Mention the capacity under which the claim is being made by the claimant (Attach the written complaint/notice given by the claimant)","options":[],"required":null,"pdf_field":""},{"help":"Details of property damage if any","type":"text","label":"Has the accident caused damage to property? If so, give name/s and address/es of the owner/s of the property and full description of the property and state the nature and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed as compensation","type":"amount","label":"Mention the amount of compensation claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Compromise Details","fields":[{"help":"","type":"yes-no","label":"Do you agree that you are liable for the incident.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain reasons for liability or denial","type":"text","label":"Give reasons","options":[],"required":null,"pdf_field":""},{"help":"Explain reasons and strategy for compromise or settlement","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game-plans/strategy for the same.","options":[],"required":null,"pdf_field":""},{"help":"Current status of negotiations","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"Amount of liability proposed","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the incident ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copies if yes","type":"yes-no","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of parties involved","type":"text","label":"Details of the main Parties of the legal Proceedings","options":[],"required":null,"pdf_field":""},{"help":"Attach copies if yes","type":"yes-no","label":"Has the court passed any interim or final order? If yes, please provide copies of the same","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach all court documents submitted","type":"attachment","label":"Also provide copies of all the documents that have been submitted to the Court either by you or the Claimants.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Legal Advice","fields":[{"help":"Describe proposed response","type":"text","label":"The Insured's proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the insured propose to/has already availed of, any legal advise.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide lawyer details and opinion","type":"text","label":"If Yes, details of the lawyer/law firm together with their opinion","options":[],"required":null,"pdf_field":""},{"help":"Describe proposed evaluation steps","type":"text","label":"If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":null,"pdf_field":""},{"help":"Estimate of legal costs","type":"amount","label":"Estimated Legal/Defence Cost/fees which will be incurred","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"Provide any additional evidence","type":"text","label":"Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance if any","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Settlement Details","fields":[{"help":"Amount agreed in settlement","type":"amount","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants?","options":[],"required":null,"pdf_field":""},{"help":"Attach proof documents","type":"attachment","label":"Please provide proof of the following (agreement, understanding, court order, court award etc)","options":[],"required":null,"pdf_field":""},{"help":"Court imposed liability amount","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you?","options":[],"required":null,"pdf_field":""},{"help":"Attach court award copy","type":"attachment","label":"Please provide copy of the court award.","options":[],"required":null,"pdf_field":""},{"help":"Total defence costs incurred","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"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":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["The completion and return of this form to the Company should not be delayed if any of the particulars required cannot be immediately given, they may be forwarded to the Company afterwards as soon as possible.","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 Policy claims for medical establishments","attachments":["Attach copies of court notices/summons if received","Attach copies of court orders if any","Attach all documents submitted to court by insured or claimants","Attach written complaint/notice given by claimant","Attach proof of settlement (agreement, court order, award etc)","Attach copy of court award if applicable"],"declarations":["The statements/information given in this form are true, correct and complete.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and rights to recover claims.","Receipt of this form or documents does not constitute agreement by the Company to the claim; the Company may require further information or reject the claim.","Consent is given to the Company to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC purposes."],"dropped_labels":0},"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/463-claim-settlement-form-of-professional-indemnity-policy-for-medical-establishment"}