{"id":477,"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)-retail.pdf","sha256":"0e5b4714b7b8e48da0e80a14aae73d02a8e0a1adc8524dc459e73eb801250f15","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is for insured persons to report and claim under Public Liability Insurance for Industrial Risks. It is filled by the insured party who has experienced an accident or loss.","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 forwarded later.","In case of third-party property damage/bodily injury, file an FIR if applicable as per policy terms.","A licensed surveyor will be appointed within 24 hours of claim reporting if eligible.","Submit all relevant documents to the assigned Claims Manager or Surveyor.","Assessment report will be furnished within 15 days of receipt of claim form and documents; claim decision within 7 days of assessment.","Use original documents where required.","Attach all relevant supporting documents as listed.","The form includes multiple parts to be filled as the claim progresses: incident reporting, claim application/consent, and settlement details."],"title":"CLAIM FORM FOR PUBLIC LIABILITY INSURANCE - INDUSTRIAL RISKS","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; Email: customersupport@icicilombard.com"},"purpose":"claim","sections":[{"title":"Incident Reporting","fields":[{"help":"","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":"Date when the accident occurred","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"If already assigned","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Date of filling the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Location where accident happened","type":"text","label":"Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident in detail","type":"text","label":"Brief description of the accident (attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Time in HH:MM format","type":"text","label":"Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Describe any steps taken to reduce loss","type":"text","label":"What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance policies covering this risk","type":"text","label":"Give particulars of any other Insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"Details of authority reporting and attach copy of report","type":"text","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":[],"required":null,"pdf_field":""},{"help":"Name of insured or reporting person","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Full address of insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number of insured","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Nearby landmark for address","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"City of insured","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"State of insured","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Politically Exposed Persons declaration","type":"yes-no","label":"Are you or any of the proposed applicants a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain relationship and position","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","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 the insured person","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Application / Consent Requisition","fields":[{"help":"","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Name of insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Nearby landmark","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"City","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"State","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Date of accident","type":"date","label":"Date of Occurance","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Type of accident","type":"text","label":"Nature of accident (Such as Boiler explosion, Gas Leak etc.)","options":[],"required":null,"pdf_field":""},{"help":"Describe accident","type":"text","label":"Brief description of accident (Attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Time in HH:MM","type":"text","label":"Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Describe consequences","type":"text","label":"Details of loss / injury / death / damage","options":[],"required":null,"pdf_field":""},{"help":"Count of affected persons","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Details of victims","type":"text","label":"Give name/es, address/es occupation/s of such person/s","options":[],"required":null,"pdf_field":""},{"help":"Location of victims during accident","type":"text","label":"State where such person were at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Medical treatment details","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":"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":"Details of court case status and 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":"Attach copies of court notices/summons","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":"Admission of 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 settlement","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":"Amount proposed for liability","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":false,"pdf_field":""},{"help":"Evidence supporting compromise","type":"text","label":"What are the circumstances/evidence that favour a compromise?","options":[],"required":false,"pdf_field":""},{"help":"Details of evidence and witnesses","type":"text","label":"Statement from witness, sketch plans, photographs, visual records of evidence / circumstance, video recording to establish the liability.","options":[],"required":false,"pdf_field":""},{"help":"Witness details","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","type":"attachment","label":"Internal investigation report, if any","options":[],"required":false,"pdf_field":""},{"help":"Attach FIR or police report","type":"attachment","label":"FIR / Investigation Report of police.","options":[],"required":false,"pdf_field":""},{"help":"Attach Pollution Control Board report if relevant","type":"attachment","label":"Pollution Control Board Report, if applicable","options":[],"required":false,"pdf_field":""},{"help":"Attach survey or investigation report on property damage","type":"attachment","label":"Survey / Investigation Report on the damaged Property, if any","options":[],"required":false,"pdf_field":""},{"help":"Attach legal or expert opinions","type":"attachment","label":"Legal opinion / Expert's opinion on admission of liability/appeal Any other circumstance/evidence.","options":[],"required":false,"pdf_field":""},{"help":"Details of claims made against insured","type":"text","label":"Has any person made any claim upon you? 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":"Estimated liability amount","type":"amount","label":"Estimated quantum of liability under (ii) and (iii) above","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, and copies of all the documents.","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","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 insured","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Settlement Details","fields":[{"help":"","type":"text","label":"Cover Note / Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"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 of settlement","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":false,"pdf_field":""},{"help":"Attach court award copy","type":"attachment","label":"Please provide copy of the court award.","options":[],"required":false,"pdf_field":""},{"help":"Total defence expenses","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","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 insured","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability Insurance - Industrial Risks","attachments":["Separate sheets describing the accident if necessary","Copy of report submitted to authority (e.g. Meteorological Report, Pollution Control Report)","Internal investigation report, if any","FIR / Investigation Report of police","Pollution Control Board Report, if applicable","Post Mortem Report / Medical Certificate, if applicable","Survey / Investigation Report on the damaged Property, if any","Legal opinion / Expert's opinion on admission of liability/appeal","Copies of court notices / summons","Copies of court orders","Copies of all documents submitted to the court","Proof of settlement (agreement, court order, court award etc.)","Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Documents in support of admissibility of the claim","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs","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 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 approval of claim.","Consent/Claim Application Form receipt does not constitute approval for settlement and company reserves the right to reject or require further information.","The insured agrees to allow the company to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes.","If any false or fraudulent statement is made, the claim shall be forfeited and the policy null and void."],"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/477-claim-form-for-public-liability-insurance-industrial-risks"}