{"id":468,"title":"CLAIM FORM PROFESSIONAL INDEMNITY POLICY FOR CHARTERED ACCOUNTANTS/ FINANCIAL ACCOUNTANTS/MANAGEMENT CONSULTANTS/LAWYERS/ ADVOCATES/SOLICITORS/ COUNSELS","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-chartered-accountants-retail.pdf","sha256":"08ef147cff2c06e82f95392f6d026178b41e89085c433b214237b26ee9327fb4","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is for insured professionals such as Chartered Accountants, Financial Accountants, Management Consultants, Lawyers, Advocates, Solicitors, and Counsels to report and claim under their Professional Indemnity Policy.","notes":["The issue of this form is not to be taken as an admission of liability.","Do not delay submission of the form if all particulars are not immediately available; they may be sent later.","Insured shall not enter into compromise/settlement without written permission of the Company.","Attach all relevant supporting documents as specified in the form.","Use the toll-free number 1800 2666 or email customersupport@icicilombard.com for assistance.","Claim reference number will be provided upon claim registration for future correspondence."],"title":"CLAIM FORM PROFESSIONAL INDEMNITY POLICY FOR CHARTERED ACCOUNTANTS/ FINANCIAL ACCOUNTANTS/MANAGEMENT CONSULTANTS/LAWYERS/ ADVOCATES/SOLICITORS/ COUNSELS","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 if applicable","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 in the form","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 of the PEP","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":"Details of Claim","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":"Date when claim was made","type":"date","label":"Date of claim","options":[],"required":null,"pdf_field":""},{"help":"Claim amount in currency","type":"amount","label":"Amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Specify claimant's capacity","type":"text","label":"Capacity in which the claimant is making the claim (i.e. as client, third party, any other)","options":[],"required":null,"pdf_field":""},{"help":"Describe the allegation; attach claim notice copy","type":"text","label":"Allegation in the claim (Please attach a copy of the claim notice)","options":[],"required":null,"pdf_field":""},{"help":"Details if claim is anticipated","type":"text","label":"In case you anticipate a claim, please specify","options":[],"required":false,"pdf_field":""},{"help":"Explain reason for anticipated claim","type":"text","label":"The reason why you anticipate such a claim","options":[],"required":false,"pdf_field":""},{"help":"Describe error or omission","type":"text","label":"Nature of error or omission if any on your part","options":[],"required":false,"pdf_field":""},{"help":"Specify source and expected time of claim","type":"text","label":"From whom and when you anticipate such a claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Details","fields":[{"help":"Describe professional service rendered","type":"text","label":"Mention the type of professional service provided to the Claimant / prospective claimant","options":[],"required":null,"pdf_field":""},{"help":"Date service was provided","type":"date","label":"When was the service provided to Claimant / prospective claimant","options":[],"required":null,"pdf_field":""},{"help":"Describe discovery of error/omission","type":"text","label":"When and how did you first come to know of the error/omission","options":[],"required":null,"pdf_field":""},{"help":"Location related to the incident","type":"text","label":"Address of the location/construction site where the error/negligence has occurred","options":[],"required":false,"pdf_field":""},{"help":"Describe 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":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Claims Reporting Form","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Date and time when error or omission 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":false,"pdf_field":""},{"help":"Qualification of alleged person","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"Describe the event briefly","type":"text","label":"Brief description of the event","options":[],"required":null,"pdf_field":""},{"help":"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 damage; 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":false,"pdf_field":""},{"help":"Count of victims involved","type":"number","label":"Number of victims","options":[],"required":false,"pdf_field":""},{"help":"Claimant's capacity 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":"","type":"yes-no","label":"Has the accident caused damage to property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of damaged property and owners","type":"text","label":"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":false,"pdf_field":""},{"help":"Compensation amount claimed","type":"amount","label":"Mention the amount of compensation claimed","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Details of compromise or settlement strategy","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game-plans/strategy for the same.","options":[],"required":false,"pdf_field":""},{"help":"Current status of negotiations","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":false,"pdf_field":""},{"help":"Proposed liability amount","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":false,"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 of court notices/summons if any","type":"text","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":[],"required":false,"pdf_field":""},{"help":"Attach copies of court orders if any","type":"text","label":"Has the court passed any interim or final order? If yes, please provide copies of the same","options":[],"required":false,"pdf_field":""},{"help":"Attach all court submitted documents","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":false,"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":false,"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/law firm details and opinion","type":"text","label":"If Yes, details of the lawyer/law firm together with their opinion","options":[],"required":false,"pdf_field":""},{"help":"Describe proposed steps to evaluate legal risk","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":false,"pdf_field":""},{"help":"Estimate of legal or defense costs","type":"amount","label":"Estimated Legal/Defence Cost/fees which will be incurred","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Details of other insurance policies if any","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Settlement Form","fields":[{"help":"State settlement amount and attach proof","type":"text","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants? Please provide proof of the following (agreement, understanding, court order, court award etc)","options":[],"required":null,"pdf_field":""},{"help":"State court imposed liability and attach award copy","type":"text","label":"If decided by a court, what is the quantum of liability imposed on you? Please provide copy of the court award.","options":[],"required":false,"pdf_field":""},{"help":"Total defense costs incurred so far","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","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":"Signature of the insured person","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Professional Indemnity Policy claims for Chartered Accountants, Financial Accountants, Management Consultants, Lawyers, Advocates, Solicitors, Counsels","attachments":["Copy of the claim notice","Written complaint/notice given by the claimant","Copies of court notices/summons if any","Copies of court orders if any","All documents submitted to the Court by you or the Claimants","Proof of settlement (agreement, understanding, court order, court award etc)","Copy of the court award if decided by court"],"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 and 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":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/468-claim-form-professional-indemnity-policy-for-chartered-accountants-financial-acc"}