{"id":479,"title":"CLAIMS FORM FOR SMART WALLET SECURE POLICY","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/smart-wallet-secure-insurance-policy--retail.pdf","sha256":"3583b1511ae6d1e253729fc6f887a4830f1f5cbac260cde8df79f6c13e31bc08","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for policyholders to file a claim under the Smart Wallet Secure insurance policy with ICICI Lombard General Insurance Company Limited.","notes":["Fill the form in Block Letters","Tick the boxes where appropriate","Do not leave any column unanswered","Attach original and relevant documents as listed","File an FIR in case of third-party property damage/bodily injury or fire if applicable","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting","Use the claim reference number for all future correspondence"],"title":"CLAIMS FORM FOR SMART WALLET SECURE POLICY","submit":{"to":"Assigned Claims Manager (CSM) or Surveyor","how":"Submit documents to assigned CSM/Surveyor as instructed","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insured person","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter current profession or occupation","type":"text","label":"Profession or Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number and email address","type":"text","label":"Mobile Number and E-mail Address","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"General Claim Details","fields":[{"help":"Enter date and time when loss or accident occurred","type":"date","label":"Date and Time of Loss/ Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter date when loss was first noticed","type":"date","label":"Date when Loss was discovered","options":[],"required":null,"pdf_field":""},{"help":"Enter location where loss or accident happened","type":"text","label":"Place of Loss/ Accident","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description of the accident","type":"text","label":"Description of the Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter the estimated amount of loss","type":"amount","label":"Amount of Loss","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, attach copy of police complaint","type":"yes-no","label":"Was the Loss Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if claim is under Lost card Liability","type":"text","label":"Additional Details in case of claim under ‘Lost card Liability","options":[],"required":false,"pdf_field":""},{"help":"Enter lost or stolen card number","type":"text","label":"Card Number","options":[],"required":false,"pdf_field":""},{"help":"Enter name of the bank issuing the card","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Select whether card was stolen or lost","type":"choice","label":"Was the card Stolen or Lost","options":["Stolen","Lost"],"required":false,"pdf_field":""},{"help":"Enter date when card insurer was informed","type":"date","label":"Date of Intimation to Card Insurer","options":[],"required":false,"pdf_field":""},{"help":"Fill only if claim is under Personal Liability","type":"text","label":"Additional Details in case of claim under ‘Personal Liability","options":[],"required":false,"pdf_field":""},{"help":"Describe consequences of the accident","type":"text","label":"Particulars of consequences of the accident:","options":[],"required":false,"pdf_field":""},{"help":"Provide details of injured persons if any","type":"text","label":"Has any person sustained any injuries in the accident. If so, Give name/s, address/s and occupation/s of such person/s","options":[],"required":false,"pdf_field":""},{"help":"State location of injured person at accident time","type":"text","label":"State where such person was at the time of accident","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No; PEP means Politically Exposed Person","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":"policyholder"},{"title":"Additional Claim Details","fields":[{"help":"Provide hospital or medical treatment details if applicable","type":"text","label":"Have the injured persons been removed to hospital or medically attended? If so, give particulars.","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any claims made against you","type":"text","label":"Has any claim been made upon you by any person, 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":""}],"filled_by":"policyholder"},{"title":"Previous Loss History (if any)","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Was there any such similar incident reported earlier","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Describe actions taken for previous incidents","type":"text","label":"If yes, what action you had taken","options":[],"required":false,"pdf_field":""},{"help":"Describe previous incident briefly","type":"text","label":"Brief Description of the incident","options":[],"required":false,"pdf_field":""},{"help":"Provide details of previous insurance covering similar incidents","type":"table","label":"Sr no., Name of the Insurance Company, Policy Number, Period of Insurance","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Medical Certificate (in case of Personal Accident Claim)","fields":[{"help":"Enter full name of injured or deceased person","type":"text","label":"Name of Injured/Deceased","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Describe nature and cause of accident","type":"text","label":"Nature and cause of Accident","options":[],"required":true,"pdf_field":""},{"help":"Specify left or right if injury is to eye or limb","type":"text","label":"If to eye or limb, state left or right.","options":[],"required":false,"pdf_field":""},{"help":"Confirm if injuries match accident description","type":"yes-no","label":"Whether to appearance of the injuries are consistent with the account given of the accident.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter date of first medical attendance","type":"date","label":"Date on which you first attended claimant for the injury","options":[],"required":true,"pdf_field":""},{"help":"State duration of total disablement","type":"text","label":"Has claimant been totally prevented from attending to any portion of his/her business/occupation/normal duties? If so for how long?","options":[],"required":true,"pdf_field":""},{"help":"Provide details of other illnesses if any","type":"text","label":"Is claimant suffering from any disease or illness apart from his injury and is there any illness by circumstances which may tend to retard recovery? If so, give particulars.","options":[],"required":false,"pdf_field":""},{"help":"Provide details if intoxication was involved","type":"text","label":"Was injured/ deceased under the influence of intoxication/ drugs at the time of accident? If yes, please provide details of diagnosis done and alcohol content","options":[],"required":false,"pdf_field":""},{"help":"Describe current condition of patient","type":"text","label":"Present condition of the patient","options":[],"required":true,"pdf_field":""},{"help":"Estimate duration of total and partial disablement","type":"text","label":"How long from the happening of the accident do you consider? a. Total disablement will last b. Partial disablement will last","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature certifying the medical certificate","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration Number","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Declarations and Signatures","fields":[{"help":"Agree to the declaration by ticking","type":"checkbox","label":"I hereby declare that the foregoing statements are true in all respects and that I have not attempted to conceal from the Company anything with which it ought to be made acquainted and also that if I have made or in any further declaration the Company may require shall make any false or fraudulent statement or any suppression, concealment or untrue averment whatever, the Policy shall be void and my right to compensation forfeited and am willing if required, to make a statutory Declaration before a Justice of the Peace of the truth of the whole of the foregoing statement or any other statement we may make in connection with this claim.","options":[],"required":true,"pdf_field":""},{"help":"Consent to KYC verification","type":"checkbox","label":"I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof as well as the identity /address proof of the Insured / Beneficial Owner through Central KYC Registry or UIDAI or through any other modes for the purpose of undertaking KYC.","options":[],"required":true,"pdf_field":""},{"help":"Name of the insured or claimant signing","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Witness","options":[],"required":true,"pdf_field":""},{"help":"Signature of insured or claimant","type":"signature","label":"Signature of the Insured/ Claimant","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Address of the insured or claimant","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder / claimant"}],"deadlines":["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":"claims under Smart Wallet Secure Policy","attachments":["Copy of police complaint (if loss reported to police)","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim (e.g. Service Engineer’s Report, Fire Brigade Report)","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 (if not repaired or reinstated)","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 specified by the surveyor post initial survey"],"declarations":["The statements made in the form are true and no information is concealed","False or fraudulent statements will void the policy and forfeit compensation","Consent is given to the company to verify identity/address proofs through official registries for KYC"],"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/479-claims-form-for-smart-wallet-secure-policy"}