{"id":476,"title":"CLAIM FORM FOR PUBLIC LIABILITY INSURANCE - INDUSTRIAL RISKS","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/public-liability-(industrial-risks)-commercial8c0007ff45fd68ff8a0df0055faee691.pdf","sha256":"3f7d4cc033b8c08c2e6e9aba3b6eaec2efbb4817efa7abe9c1f83946b5417c02","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is for filing a claim under Public Liability Insurance for Industrial Risks. It is filled by the insured party who has experienced or is reporting an accident covered under the 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; missing information may be sent later.","Attach separate sheets if the space provided is insufficient.","Attach copies of all relevant reports and documents as requested.","The insured must not enter into compromise or settlement without written permission of the Company."],"title":"CLAIM FORM FOR PUBLIC LIABILITY INSURANCE - INDUSTRIAL RISKS","submit":{"to":"The Company (ICICI Lombard General Insurance Company Limited)","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Accident and Policy Details","fields":[{"help":"Enter your insurance policy or cover note number","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the accident occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter the claim number if already assigned","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of filling this form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the location where the accident happened","type":"text","label":"Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident briefly; attach extra sheets if needed","type":"text","label":"Brief description of the accident (attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Enter the time of the accident in HH:MM format","type":"text","label":"Time of Occurrence","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Describe any steps taken to reduce the loss","type":"text","label":"What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies covering the same risk","type":"text","label":"Give particulars of any other Insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if the accident was reported to any authority and attach the report","type":"yes-no","label":"HAS THE ACCIDENT BEEN REPORTED TO ANY AUTHORITY? IF SO, STATE BY WHOM AND ATTACH A COPY OF THE REPORT SUBMITTED (LIKE METEOROLOGICAL REPORT, POLLUTION CONTROL REPORT ETC.)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insured","fields":[{"help":"Enter the insured's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the insured's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter a contact phone number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Enter a nearby landmark for the address","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter the city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal pin code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Enter the state","type":"text","label":"State","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Person (PEP) Declaration","fields":[{"help":"Select Yes or No","type":"choice","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 answered Yes above","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":"Claim Application / Consent Requisition","fields":[{"help":"Enter your insurance policy or cover note number","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the accident occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter the claim number if already assigned","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the insured's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the insured's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter a contact phone number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Enter a nearby landmark for the address","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter the city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal pin code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Enter the state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of the accident","type":"date","label":"Date of Occurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the location of the accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe the type of accident","type":"text","label":"Nature of accident (Such as Boiler explosion, Gas Leak etc.)","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident briefly; attach extra sheets if needed","type":"text","label":"Brief description of accident (Attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Enter the time of the accident in HH:MM format","type":"text","label":"Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Describe the consequences of the accident","type":"text","label":"Details of loss / injury / death / damage","options":[],"required":null,"pdf_field":""},{"help":"Enter the number of victims involved","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Provide details of victims","type":"text","label":"Give name/es, address/es occupation/s of such person/s","options":[],"required":null,"pdf_field":""},{"help":"Describe the location of victims at accident time","type":"text","label":"State where such person were at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details if any","type":"text","label":"Have the injured persons been removed to hospital or medically attended? If so, give particulars","options":[],"required":null,"pdf_field":""},{"help":"Indicate if property damage occurred","type":"yes-no","label":"Has the accident caused damage to property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide property owner and damage details if applicable","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":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"Provide current status and next hearing date","type":"text","label":"If yes, what is the present status of the proceedings? Also give the next date of hearing.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if court notices were received and attach copies","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":"Attach all court-related documents","type":"attachment","label":"Also provide copies of all the documents that have been submitted to the Court either by you or the Claimants, and copies of all the documents.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Compromise Details","fields":[{"help":"State your agreement on liability","type":"yes-no","label":"Do you agree that you are liable for the accident and the consequential loss/damage either to persons/property or livestock?","options":["Yes","No"],"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":"Describe current negotiation status","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"State the amount of liability proposed","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":null,"pdf_field":""},{"help":"Provide evidence supporting compromise","type":"text","label":"What are the circumstances/evidence that favour a compromise?","options":[],"required":null,"pdf_field":""},{"help":"List and describe evidence supporting liability","type":"text","label":"Statement from witness, sketch plans, photographs, visual records of evidence / circumstance, video recording to establish the liability.","options":[],"required":null,"pdf_field":""},{"help":"Provide witness details if available","type":"text","label":"Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":false,"pdf_field":""},{"help":"Attach internal investigation report if available","type":"attachment","label":"Internal investigation report, if any","options":[],"required":false,"pdf_field":""},{"help":"Attach police FIR or investigation report if applicable","type":"attachment","label":"FIR / Investigation Report of police.","options":[],"required":false,"pdf_field":""},{"help":"Attach pollution control report if applicable","type":"attachment","label":"Pollution Control Board Report, if applicable","options":[],"required":false,"pdf_field":""},{"help":"Attach survey or investigation report on property damage if any","type":"attachment","label":"Survey / Investigation Report on the damaged Property, if any","options":[],"required":false,"pdf_field":""},{"help":"Attach legal or expert opinions if available","type":"attachment","label":"Legal opinion / Expert's opinion on admission of liability/appeal Any other circumstance/evidence.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any claim has been made against you","type":"yes-no","label":"Has any person made any claim upon you?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of claimants and attach documents if available","type":"text","label":"If so, state by whom and give full particulars (if claim has been made in writing, attach a copy of the notification received and of the bill, if submitted).","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated liability amount","type":"amount","label":"Estimated quantum of liability under (ii) and (iii) above","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"Provide details of any other claims for the same loss","type":"text","label":"Details of claims if any preferred by the affected party / Insured for the same loss from another source.","options":[],"required":false,"pdf_field":""},{"help":"Provide any additional evidence supporting the claim","type":"text","label":"Any other evidence in support of claim.","options":[],"required":false,"pdf_field":""},{"help":"Provide 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":"Settlement Details","fields":[{"help":"Enter the agreed settlement amount","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 of settlement","type":"attachment","label":"Please provide proof of the following (agreement, understanding, court order, court award etc)","options":[],"required":null,"pdf_field":""},{"help":"Enter court-imposed liability amount if applicable","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you?","options":[],"required":null,"pdf_field":""},{"help":"Attach copy of court award if applicable","type":"attachment","label":"Please provide copy of the court award.","options":[],"required":null,"pdf_field":""},{"help":"Enter total defense 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":"Declarations and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability Insurance - Industrial Risks","attachments":["Separate sheets for accident description if necessary","Copy of report submitted to authorities (e.g. Meteorological Report, Pollution Control Report)","Copies of court notices, summons, orders, and related documents","Internal investigation report if any","FIR / Police Investigation Report","Pollution Control Board Report if applicable","Post Mortem Report / Medical Certificate if applicable","Survey / Investigation Report on damaged property if any","Legal opinion / Expert's opinion on admission of liability/appeal","Proof of settlement (agreement, court order, court award etc.)","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 claims.","Receipt of this form does not constitute admission of liability or claim approval.","Consent/Claim Application Form receipt does not constitute approval for settlement; permission is reserved by the Company.","The insured warrants the truth of all statements and agrees that false declarations will forfeit the claim and void the policy.","Consent is given to the Company to verify identity/address proofs through Central KYC Registry or UIDAI or other modes."],"dropped_labels":4},"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/476-claim-form-for-public-liability-insurance-industrial-risks"}