{"id":483,"title":"CLAIM FORM FOR ICICI COMPLETE HOME PROTECT","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_complete_home_protect8c0007ff45fd68ff8a0df0055fb0c440.pdf","sha256":"844bfa4d886736d65f2fd1964d9ab6f1b957ca4b962ccfbebcd4c310f5bf2996","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for policyholders to notify and claim for physical loss or damage under the ICICI Complete Home Protect insurance policy.","notes":["Attach original copies of other insurance policies if applicable.","Attach copy of FIR for burglary/theft claims.","Attach copies of written claim notifications and bills if any under personal liability.","The issue of this form is not an admission of liability.","Answer all questions fully."],"title":"CLAIM FORM FOR ICICI COMPLETE HOME PROTECT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"DETAILS OF INSURED","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":"If applicable, provide details of mortgagee or other financial interest holders","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"DETAILS OF OTHER INSURANCE","fields":[{"help":"If insured with other companies, provide insurer name","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide policy number(s) of other insurance","type":"text","label":"Policy No. (s).","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policies","type":"amount","label":"Sum Insured Rs.","options":[],"required":null,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""},{"help":"End date of other insurance policy","type":"date","label":"To","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"DETAILS OF LOSS","fields":[{"help":"Provide exact time and date when loss occurred","type":"date","label":"Time & Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss or damage","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the insured item affected","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"State how the premises was used at time of loss","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if fire brigade was informed; if no, explain why","type":"yes-no","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Personal Accident","fields":[{"help":"Name of injured or deceased person","type":"text","label":"Name of the Person Injured/Died","options":[],"required":null,"pdf_field":""},{"help":"Location where injury or death occurred","type":"text","label":"Place of injury/ death","options":[],"required":null,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Details of the accident","options":[],"required":null,"pdf_field":""},{"help":"Indicate if accident was reported to police","type":"yes-no","label":"Whether reported to Police.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide police station details if reported","type":"text","label":"If yes then name and address of Police Station.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if person was taken to hospital immediately","type":"yes-no","label":"Was the injured /deceased person moved to hospital immediately after the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide hospital details if applicable","type":"text","label":"If yes , Name & address of the hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Living Expense","fields":[{"help":"Duration property was uninhabitable","type":"text","label":"What is the period of which property remained unfit for occupation?","options":[],"required":null,"pdf_field":""},{"help":"Amount spent on additional living expenses","type":"amount","label":"What is the Additional Living Expenses paid by the insured as a consequence of loss?","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Burglary and/or theft claim","fields":[{"help":"Specify affected part of dwelling","type":"text","label":"Which portion of the Dwelling effected by the entry/exit?","options":[],"required":null,"pdf_field":""},{"help":"Provide police complaint details and attach FIR copy","type":"text","label":"Has a complaint been lodged with the police? If so, by whom and when and at which police station? Attach copy of FIR","options":[],"required":null,"pdf_field":""},{"help":"Indicate if property was occupied during loss","type":"yes-no","label":"Was the property occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Last date and time property was occupied if unoccupied","type":"text","label":"If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"Duration property was unoccupied","type":"text","label":"For how long have the property been unoccupied?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any suspected persons","type":"text","label":"Is anybody suspected of theft? If so, state full details.","options":[],"required":null,"pdf_field":""},{"help":"Provide owner details if not sole owner","type":"text","label":"If no, the Property belongs to whom ?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if insured must repair property","type":"yes-no","label":"Is the Insured responsible for repairs to the Property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Total value of items in dwelling at loss time","type":"amount","label":"State the total value of /item (s) in the Dwelling at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Refer to Annexure I for detailed list","type":"text","label":"Value and description of Contents lost, to be given In the Annexure I.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Loss of Cash whilst in transit claim","fields":[{"help":"When loss was noticed","type":"date","label":"Date & Time when loss was discovered","options":[],"required":null,"pdf_field":""},{"help":"Route of money transit","type":"text","label":"Places between which money was in transit","options":[],"required":null,"pdf_field":""},{"help":"Describe circumstances of loss","type":"text","label":"How & where did the loss occur?","options":[],"required":null,"pdf_field":""},{"help":"Amount of money carried","type":"amount","label":"What was the amount carried?","options":[],"required":null,"pdf_field":""},{"help":"Name of person responsible for money","type":"text","label":"In whose custody was the money at the time of loss?","options":[],"required":null,"pdf_field":""},{"help":"Method of carrying money","type":"text","label":"How was the money carried?","options":[],"required":null,"pdf_field":""},{"help":"Transport used during transit","type":"text","label":"Means of transport","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Personal Liability Claim","fields":[{"help":"Describe consequences of accident","type":"text","label":"Particulars of consequences of the accident:","options":[],"required":null,"pdf_field":""},{"help":"Details of loss or injury","type":"text","label":"Details of loss / injury / death /damage","options":[],"required":null,"pdf_field":""},{"help":"Count of persons affected","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Details of victims","type":"text","label":"Give name/s, address/es and 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":"(i)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":null,"pdf_field":""},{"help":"Details of claims made against insured and attach documents if any","type":"text","label":"(ii)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":null,"pdf_field":""},{"help":"Estimated liability amount","type":"amount","label":"(iii)Estimated quantum of liability under (3) and (7) above","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Loss Details","fields":[{"help":"Value of loss to lawn and belongings","type":"amount","label":"What is amount of loss of item to the lawn and its belongings?","options":[],"required":null,"pdf_field":""},{"help":"Location of loss","type":"text","label":"Address of the home building at which loss occurred.","options":[],"required":null,"pdf_field":""},{"help":"Inspection address if different","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of loss extent","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Annexure I: List of items above INR 50,000 and Vault wise details","fields":[{"help":"List items with description and value above INR 50,000","type":"table","label":"List of items above INR 50,000 (S No, Description of item, Value (INR))","options":[],"required":null,"pdf_field":""},{"help":"List specified articles with description and value","type":"table","label":"List of items covered under Specified articles (S No, Description of item, Value (INR))","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"physical loss or damage claims under ICICI Complete Home Protect policy","attachments":["copies of other insurance policies if applicable","copy of FIR for burglary/theft claims","copy of notification and bill if claim made in writing under personal liability"],"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 the 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 concealed.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of this form or documents does not mean acceptance of the claim; the company may require more information or reject the claim."],"dropped_labels":3},"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/483-claim-form-for-icici-complete-home-protect"}