{"id":480,"title":"CLAIM FORM FOR CONSEQUENTIAL LOSS (FIRE) INSURANCE 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/claim-form-for-consequential-loss-(fire)-insurance-policy-commercial.pdf","sha256":"5e3805890fb36c245e514ab22f87d1ca47af6b838b35afb2378e9a9fc17bd11f","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to claim consequential loss under a fire insurance policy. The policyholder or insured fills it.","notes":["The issue of this form is not an admission of liability.","Please answer all questions fully.","Attach copies of relevant policies and claim settlement details if insured by other insurers.","Politically Exposed Persons (PEPs) are defined as individuals holding prominent public functions.","Use the toll free number 1800 2666 or email customersupport@icicilombard.com for assistance."],"title":"CLAIM FORM FOR CONSEQUENTIAL LOSS (FIRE) INSURANCE POLICY","submit":{"to":"ICICI Lombard General Insurance Company Ltd.","how":"","address":"Interface Building No.16, 601/602, 6th Floor, New Link Road Malad (W), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Details of Insured and Claim Information","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Specify the sum insured and indemnity period as per policy","type":"text","label":"Indemnity Sum Insured and Indemnity Period.","options":[],"required":null,"pdf_field":""},{"help":"Date and time when the fire incident occurred","type":"date","label":"Date and time of Accident.","options":[],"required":null,"pdf_field":""},{"help":"Duration for which business was interrupted","type":"text","label":"Estimated Interruption period.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the fire insurance policy and attach copy if from another insurer","type":"text","label":"Details of fire policy (indicate Sum Insured, Policy No, Insurers name). Enclose policy copy if Insured by any other Insurer.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of material damage claim and attach settlement details if from another insurer","type":"text","label":"Details of material damage claim including address of loss. Enclose details of claim settled if Insured by any other Insurer.","options":[],"required":null,"pdf_field":""},{"help":"Provide turnover figures for last and current financial years","type":"text","label":"Turnover for the previous and current Financial year.","options":[],"required":null,"pdf_field":""},{"help":"Provide gross profit figures for last and current financial years","type":"text","label":"Gross profit for the previous and current Financial year.","options":[],"required":null,"pdf_field":""},{"help":"Provide standing charges for last and current financial years","type":"text","label":"Standing charges for the previous and current Financial year.","options":[],"required":null,"pdf_field":""},{"help":"Describe the facility affected by the loss","type":"text","label":"Details of the facility affected.","options":[],"required":null,"pdf_field":""},{"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":null,"pdf_field":""},{"help":"Address of the office handling the claim","type":"text","label":"Office Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Claim Details","fields":[{"help":"Mention any alternate facility used during business interruption","type":"text","label":"Any alternate facility used in the interruption period Specify, if any","options":[],"required":false,"pdf_field":""},{"help":"List any extra costs incurred during interruption","type":"text","label":"Any additional costs incurred in the interruption period Specify, if any","options":[],"required":false,"pdf_field":""},{"help":"State the maximum rated capacity of the plant","type":"text","label":"Maximum rated capacity of the plant.","options":[],"required":null,"pdf_field":""},{"help":"State the operating capacity of the plant at time of loss","type":"text","label":"What is the capacity at which the plant was operating?","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated time to reinstate the plant/facility","type":"text","label":"Estimated time required for reinstatement.","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed for the loss","type":"amount","label":"Total loss claimed.","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant information for claim processing","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No if you or related persons are Politically Exposed Persons","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member / Close relatives / Associates close relative of a PEP*? Yes No","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":"Declarations and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Consequential loss (fire) insurance policies","attachments":["Copy of fire policy if insured by any other insurer","Details of claim settled if insured by any other insurer"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed as per proposal or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to claim processing has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this form or documents does not constitute admission of claim liability.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes."],"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/480-claim-form-for-consequential-loss-fire-insurance-policy"}