{"id":485,"title":"CLAIM FORM FOR ALL RISK INSURANCE Notification of Physical Loss or Damage","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-all-risk-insurance-commercial.pdf","sha256":"f294c29a00a846b44008a643c61ad2f3bb664a9bef919761d96237bcb5f29d04","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person to notify and claim for physical loss or damage under an All Risk Insurance policy.","notes":["Attach copy of FIR with the claim form.","The issuance of this form is not an admission of liability.","Use the Direct Fund Transfer/EFT Mandate Form to opt for electronic payment.","Terms and conditions for RTGS/NEFT payments apply as stated in the form."],"title":"CLAIM FORM FOR ALL RISK INSURANCE Notification of Physical Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence:","options":[],"required":true,"pdf_field":""},{"help":"Provide a valid phone number","type":"phone","label":"Contact Number:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"Describe the type of loss or damage","type":"text","label":"Nature of loss/ damage.","options":[],"required":true,"pdf_field":""},{"help":"List the damaged items","type":"text","label":"Details of damaged property","options":[],"required":true,"pdf_field":""},{"help":"Provide exact location of loss","type":"text","label":"Place & address where the loss took place.","options":[],"required":true,"pdf_field":""},{"help":"Provide date, time and place last seen","type":"text","label":"When and where was the missing property last seen?","options":[],"required":true,"pdf_field":""},{"help":"Provide date and time","type":"date","label":"Date and time when loss was first discovered.","options":[],"required":true,"pdf_field":""},{"help":"Explain how the loss or damage occurred","type":"text","label":"State the circumstances of the loss or damage.","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated monetary value","type":"amount","label":"Estimated value of items lost or Damaged","options":[],"required":true,"pdf_field":""},{"help":"Attach copy of FIR","type":"date","label":"Date and time of reporting the loss to Police Station. (Please furnish copy of FIR)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Police Details and Ownership","fields":[{"help":"Provide police station details","type":"text","label":"Name and address of the Police Station.","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you the sole owner of the property?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Have you ever before sustained loss of the same nature? If so, give particulars.","options":[],"required":false,"pdf_field":""},{"help":"Provide other insurance details if any","type":"text","label":"Is there any other insurance on the same property? If so, give full particulars","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant info","type":"text","label":"Any additional information relevant to processing of claim","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? Yes No If yes, please give details (Nature of relationship and position held by PEP):","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"Select Yes or No","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide name as per bank records","type":"text","label":"Payee Name (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Provide bank account number","type":"text","label":"Payee Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Select account type or specify if Others","type":"choice","label":"Type of Account: Savings Current Others (specify):","options":["Savings","Current","Others"],"required":true,"pdf_field":""},{"help":"Provide bank name","type":"text","label":"Name of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Provide branch name","type":"text","label":"Branch Name :","options":[],"required":true,"pdf_field":""},{"help":"Provide bank branch address","type":"text","label":"Address of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Provide IFSC code","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Provide MICR code if available","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN number","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Signature for EFT Mandate","fields":[{"help":"Sign here to authorize EFT","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"All Risk Insurance policies","attachments":["Copy of FIR"],"declarations":["The information given in this claim form is true, correct and complete.","All persons having interest in the property are disclosed as per the policy or endorsements.","No material information relevant to the claim has been withheld.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this form does not constitute admission of liability by the company.","Consent is given to verify identity/address through Central KYC Registry or UIDAI for KYC purposes."],"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/485-claim-form-for-all-risk-insurance-notification-of-physical-loss-or-damage"}