{"id":465,"title":"CLAIM FORM PRODUCT RECALL GUARANTEE AND FINANCIAL LOSS LIABILITY 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/product-recall-guarantee-and-financial-loss-liability-retail.pdf","sha256":"6555116732bc531664ee4a65164394fb82792e9044ec8f064751e971eefb4fd3","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the insured to file a claim under the Product Recall Guarantee and Financial Loss Liability Insurance policy.","notes":["The insured must not settle or offer to settle any claim, incur any defence costs or legal expenses, or admit liability without the insurer's prior written consent.","Claim intimation is without prejudice and insurer’s rights are reserved.","A licensed surveyor will be appointed within 24 hours of claim reporting if eligible.","Assessment sheet/survey report will be furnished within 15 days of receipt of claim form and documents.","Claim decision will be made within 7 days of receipt of assessment sheet/survey report.","In case of third-party property damage/bodily injury or fire, file an FIR if applicable as per policy terms.","Use separate pages if required to provide detailed information."],"title":"CLAIM FORM PRODUCT RECALL GUARANTEE AND FINANCIAL LOSS LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited via Claims Manager or Surveyor","how":"via toll-free number, email, website claim portal, or as directed by Claims Manager/Surveyor","address":"customersupport@icicilombard.com; https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx; Toll free no.: 1800 2666"},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of Cover:","options":[],"required":null,"pdf_field":""},{"help":"Start date of the policy period","type":"date","label":"Policy period From","options":[],"required":null,"pdf_field":""},{"help":"End date of the policy period","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retroactively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Sum insured limit under the policy","type":"amount","label":"Limit (sum Insured)","options":[],"required":null,"pdf_field":""},{"help":"Deductible amount applicable","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss event occurred","type":"date","label":"Date of Occurrence of Circumstances leading to loss","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 the jurisdiction affected by the claim","type":"text","label":"Jurisdiction affected","options":[],"required":null,"pdf_field":""},{"help":"Describe the bodily injury or property damage alleged","type":"text","label":"The nature of the alleged bodily Injury and/or property damage","options":[],"required":null,"pdf_field":""},{"help":"Date when the alleged injury or damage occurred","type":"date","label":"The date it was committed,","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature of the damage alleged","type":"text","label":"The nature of the alleged damage,","options":[],"required":null,"pdf_field":""},{"help":"List the names of all claimants","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List the defendants involved","type":"text","label":"Defendants","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering the same risk","type":"text","label":"Details of Other Insurance covering same risk","options":[],"required":null,"pdf_field":""},{"help":"Estimated monetary value of the claim","type":"amount","label":"Estimated amount of claim:","options":[],"required":null,"pdf_field":""},{"help":"Describe the sequence of events leading to the 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 other proceedings related to the claim","type":"text","label":"Status of proceedings as on date:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any applicant is a Politically Exposed Person or related","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 to previous question 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":"Attachments to be submitted with this Claim Intimation Form","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":false,"pdf_field":""},{"help":"Attach all correspondence related to the claim","type":"attachment","label":"Copy of the complete correspondence till date.","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":"Place where form is signed","type":"text","label":"Place :","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date :","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized person","type":"signature","label":"Authorised Signatory","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Product Recall Guarantee and Financial Loss Liability Insurance (Retail)","attachments":["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.","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"],"declarations":["The information furnished in this Claim Intimation Form is true, correct and complete to the best of my knowledge and belief.","I have not withheld any information material to this Claim Intimation Form.","If any untrue or false statement is made, or material fact concealed, my right to claim under the policy shall be forfeited.","I consent and authorize the Insurer to seek necessary information/documents from any third party who has made the claim against the Insured.","I give consent to the Company to verify and obtain identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes."],"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/465-claim-form-product-recall-guarantee-and-financial-loss-liability-insurance"}