{"id":481,"title":"CLAIM FORM: ICICI Lombard Group Criti shield plus","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/4202-group-criti-shield-plus_-claim-form.pdf","sha256":"4aa0250fd2d1f92139d153c2814b4e50337cbd05d11c77a8989d59d8f9a8d855","pages":20,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the ICICI Lombard Group Criti Shield Plus insurance policy.","notes":["Attach a separate sheet if space is insufficient for details.","Use original bills and documents as specified.","If claim amount exceeds ₹1 lakh, submit AML documents including PAN card, residence proof, and photos.","Nominee’s bank account details are required in case of a death claim.","Use block letters where applicable.","Claim can be lodged via website, phone, email, or branch visit.","Ensure all KYC documents are submitted as per guidelines.","The insured person/claimant must sign where indicated.","The form includes annexures listing covered critical illnesses and surgical procedures for reference."],"title":"CLAIM FORM: ICICI Lombard Group Criti shield plus","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post / e-mail / visit branch / phone / website","address":"Mailing Address: ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016; Email: ihealthcare@icicilombard.com; Toll Free Number: 1800 2666; Website: www.icicilombard.com"},"purpose":"claim","sections":[{"title":"PART –I: Customer related details","fields":[{"help":"Enter your policy number as per your policy document","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the proposer of the policy","type":"text","label":"Name of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the insured person","type":"text","label":"Name of the Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Insured Date of birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender: Male / Female / Third gender","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter Aadhaar number of the insured person","type":"text","label":"Aadhaar Card No. of Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's name if different from insured person","type":"text","label":"Name of claimant","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship if claimant is not the insured person","type":"text","label":"Relationship of claimant with Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Enter full address for communication","type":"text","label":"Address for communication","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile and/or residential phone number","type":"phone","label":"Contact Details: Mob. / Res. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"Enter Aadhaar number of claimant if different from insured person","type":"text","label":"Aadhaar Card No. of claimant","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"Do You have any other insurance for similar claim (either with Us or with any other insurer) - If yes please specify details","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"C. Loan Details","fields":[{"help":"Enter name of financial institution if policy linked to loan","type":"text","label":"Name of the Financial Institution","options":[],"required":null,"pdf_field":""},{"help":"Enter Loan Account Number","type":"text","label":"LAN No.","options":[],"required":null,"pdf_field":""},{"help":"Enter EMI amount","type":"amount","label":"EMI amount","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant if policy linked to loan"},{"title":"C. Other Financial Instrument Details","fields":[{"help":"Tick yes or no if policy is assigned","type":"choice","label":"Is Policy assigned: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name of financial institution if assigned","type":"text","label":"Name of the Financial Institution","options":[],"required":null,"pdf_field":""},{"help":"Enter folio number or other instrument details","type":"text","label":"Folio No. in case of SIP or (Details of other instrument if not linked to SIP)","options":[],"required":null,"pdf_field":""},{"help":"Enter SIP amount","type":"amount","label":"SIP amount","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant if policy linked to financial instrument"},{"title":"PART- II: Claim Details","fields":[{"help":"Enter claim number if already registered","type":"text","label":"Claim No. (If claim has already been registered with ICICI Lombard Health Care)","options":[],"required":false,"pdf_field":""},{"help":"Describe the loss or event in detail","type":"text","label":"Description of Loss/Event","options":[],"required":true,"pdf_field":""},{"help":"Tick yes or no if FIR was filed","type":"choice","label":"Was any FIR done: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter police station location if FIR done","type":"text","label":"Location of police station in which FIR registered","options":[],"required":false,"pdf_field":""},{"help":"Enter FIR number if FIR done","type":"text","label":"FIR no.","options":[],"required":false,"pdf_field":""},{"help":"Explain reasons if FIR was not filed","type":"text","label":"In case FIR was not done, please state the reasons for same","options":[],"required":false,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"PART III: Hospital Details if applicable","fields":[{"help":"Tick medical or surgical treatment","type":"choice","label":"Particulars of treatment: Medical / Surgical","options":["Medical","Surgical"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"For any Critical Illness, date when the Critical Illness was first diagnosed","options":[],"required":false,"pdf_field":""},{"help":"Enter admission date and time (AM/PM)","type":"date","label":"Date and time of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter discharge date and time (AM/PM)","type":"date","label":"Date and time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter number of ICU days","type":"number","label":"Number of days in ICU (if any)","options":[],"required":false,"pdf_field":""},{"help":"Tick reason for admission","type":"choice","label":"Reasons for admission: Medical / Accident","options":["Medical","Accident"],"required":null,"pdf_field":""},{"help":"Tick yes or no if MLC was done","type":"choice","label":"In case of admission due to Accident: Was any MLC done: Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick yes or no if post mortem was done","type":"choice","label":"In case of death: Was any post mortem done: Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify any pre-existing disease","type":"text","label":"Was Insured Person suffering from any Pre-Existing Disease","options":[],"required":false,"pdf_field":""},{"help":"Signature required","type":"signature","label":"Signature of the Insured Person/claimant/Competent authority at treating Hospital (Hospital 1, 2, 3)","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant/Hospital authorities"},{"title":"Additional information For Loss of pay / Loss of Income on account of loss of Employment","fields":[{"help":"Enter employer details","type":"text","label":"Name and address of the employer/company and other details (business model)","options":[],"required":null,"pdf_field":""},{"help":"Enter designation","type":"text","label":"Designation/of the insured","options":[],"required":null,"pdf_field":""},{"help":"Specify employment type and contract details if applicable","type":"text","label":"Whether employed on Permanent /contractual basis (letter/period of contract if on contractual basis)","options":[],"required":null,"pdf_field":""},{"help":"Enter total number of leaves allotted","type":"number","label":"Total no of Sick/Casual/Privileged/Paid or any other such leave allotted/granted by the employer","options":[],"required":null,"pdf_field":""},{"help":"Enter number of leaves utilized","type":"number","label":"Out of which total no of leaves been utilised/exhausted by insured","options":[],"required":null,"pdf_field":""},{"help":"Enter expected duration of loss of pay","type":"text","label":"Estimated /expected Duration /period of loss of pay","options":[],"required":null,"pdf_field":""},{"help":"Specify illness or disablement triggered","type":"text","label":"Critical illness/Personal accident – Permanent Total Disablement- Permanent Partial Disablement triggered","options":[],"required":null,"pdf_field":""},{"help":"Enter total unemployment period","type":"text","label":"Total period of unemployment","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no and provide re-employment date if yes","type":"text","label":"Whether re-employed (yes/no) if yes, please mention the date of re-employment","options":["yes","no"],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"Benefit Selection","fields":[{"help":"Tick the benefits you are claiming for as per your policy","type":"checkbox","label":"Please tick against each of the Benefit under which you are claiming for, as per the relevant Section and Benefits","options":["Benefit 1.1 Comprehensive Critical Illness 57 Critical Illnesses","Benefit 1.2 42 Critical Illnesses","Benefit 1.3 57 Critical Illnesses","Benefit 2 Extensive Critical Illness 6 Critical Illnesses","Benefit 3 Cancer Restore Benefit","Benefit 4 Major Surgical Procedures","Benefit 5 Accidental Death Benefit","Benefit 6 Permanent Total Disablement (PTD)","Benefit 7 Permanent Partial Disablement (PPD)","Benefit 8 Loss of Pay","Benefit 9 Loss of Income on account of loss of Employment","Benefit 10 ICU Benefit"],"required":null,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"PART- IV: NEFT Details","fields":[{"help":"Enter name as per bank records","type":"text","label":"Claimant /Insured Person’s name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Claimant /Insured Person’s bank account no.","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank address","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code as per cheque leaf","type":"text","label":"IFSC code no. of the bank","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"PART - V: KYC (KNOW YOUR CUSTOMER)","fields":[{"help":"Enter full name","type":"text","label":"Claimant/Insured Person's Name (in respect of whom claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter claim number if available","type":"text","label":"Claim Number (if allotted)","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile or contact number","type":"phone","label":"Mobile/ Contact No.","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""},{"help":"Paste two passport size photos in the space provided","type":"photo","label":"Two passport size photos of Insured Person/claimant","options":[],"required":true,"pdf_field":""},{"help":"Attach one valid identity proof","type":"attachment","label":"One photocopy of proof of identity of Insured Person/claimant (any 1 in the list)","options":["Passport","PAN card","Voter’s Identity card","Driving license","Personal identification and certification of the employees of the insurer","Letter issued by UIDAI containing name, address and Aadhaar number","Job card issued by NREGA","Letter from recognized Public Authority or Public Servant verifying identity and residence"],"required":true,"pdf_field":""},{"help":"Attach one valid residence proof","type":"attachment","label":"One photocopy of proof of residence of Insured Person/claimant (any 1 in the list)","options":["Electricity bill","Ration card","Letter from recognized public authority","Current bank statement with address","Current passbook with address","Valid lease agreement with rent receipt (not older than 3 months)","Telephone bill (not older than 6 months)","Employer’s certificate as proof of residence"],"required":true,"pdf_field":""}],"filled_by":"Insured Person/claimant"},{"title":"Claimant/Insured Person Declaration","fields":[{"help":"Enter full name","type":"text","label":"Name of the Insured Person/claimant/Nominee","options":[],"required":true,"pdf_field":""},{"help":"Specify relation","type":"text","label":"Relation with the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured Person/claimant"}],"deadlines":[],"applies_to":"Claims under ICICI Lombard Group Criti Shield Plus policy","attachments":["Two passport size photos of Insured Person/claimant","One photocopy of proof of identity of Insured Person/claimant","One photocopy of proof of residence of Insured Person/claimant","EMS Paper","Hospital discharge summary","Police report","Letter from employer stating reason for loss of pay and leave policy","Discharge Card/Summary papers","All pre and post-surgery investigation reports/scans","MLC / FIR","Letter from medical practitioner mentioning unfit to resume work","Indoor Case papers","Scan copy of original Policy copy","Cause of Death Schedule","Appointment letter and confirmation letter issued by employer","Death certificate issued by Government Authority","Letter from HR mentioning balance leaves at diagnosis","Document confirming payment of claim under Critical Illness cover","Hospital Bills","Consultation papers of surgeon advising surgical procedure","Post Mortem Report","All Investigation Reports – blood, pathology, radiology, etc.","Schedule by treating Medical Practitioner confirming diagnosis","Copies of Indoor case papers from Hospital","Viscera / Chemical Analysis / Forensic Report","Contact details of Human Resource Personnel","Certificate by treating Medical Practitioner confirming diagnosis","Current and past consultation papers","Income Proof (ITR/Salary Slip, etc.)","Police Final Charge sheet / Termination letter and relieving letter","Court Final Order from employer or documents stating reason for termination/retrenchment","Medical Cause of Death issued by last attending Medical Practitioner","Spot Inquest / Panchnama","Salary structure and last 3 months salary slips","Certificate of Medical Cause of Death","Schedule from last attending Medical Practitioner for underlying medical conditions","RACT award in case of rail accident","Original Amortization Chart for loan linked policy","Post Mortem Report, FSL Report, Viscera and Chemical Analysis Report, Histopathology Report","Indoor Case Papers/Hospitalisation records and Discharge summary","Form-16 from employer, Income Tax Return of last 3 years","Any other specific investigation/document to support diagnosis","All histology/cytology/FNAC/Biopsy/Immuno-chemistry reports, X-ray, CT Scan, MRI, PET Scan, Bone Marrow Test, Cancer Markers","ICU admission papers","Disability Schedule by Civil Surgeon / Government Hospital","Proof for advice on ICU admission by Medical practitioner","Cancelled cheque and NEFT mandate form duly filled","Pan Card Copy, Residence Proof, and 2 passport sized colour photos if claim amount is more than ₹1 lakh"],"declarations":["The statements/information provided in the claim form are true, correct and complete.","No material information relevant to claim processing has been withheld or not disclosed.","ICICI Lombard is authorized to collect medical and other relevant information for claim assessment.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of claim form or documents does not imply admission of claim liability by ICICI Lombard.","Policy may be voided for untrue or incorrect statements or non-disclosure in claim form or related documents.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes.","Claim payment will be credited after confirmation from bankers and the RTGS/NEFT facility terms apply.","Claimant agrees to refund any excess amount credited in error within 7 days of notification.","ICICI Lombard is not responsible for non-payment due to changes in RTGS/NEFT regulations or other reasons beyond its control.","Claimant indemnifies ICICI Lombard against any claims or losses arising from RTGS/NEFT transactions.","Claimant may terminate RTGS/NEFT facility with 15 days written notice to ICICI Lombard at corporate address.","Terms and conditions for RTGS/NEFT facility may be amended with prior notice and acceptance is implied by continued use.","Submission of documents or bank details does not imply admission of liability by ICICI Lombard."],"dropped_labels":5},"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/481-claim-form-icici-lombard-group-criti-shield-plus"}