{"id":487,"title":"CLAIM FORM FOR ALL RISK INSURANCE","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-retail.pdf","sha256":"0163f6bd269e8219fdcea8d50c079536d78de1fd64f724bc860b5cb720dc1575","pages":5,"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":["The issuance of this form is not an admission of liability.","Please answer all questions fully.","Attach original documents as specified.","Use the claim reference number for future correspondence.","For third-party property damage or bodily injury, file an FIR if applicable.","Surveyor will be appointed within 24 hours of claim reporting.","Claim payment will be made via Electronic Fund Transfer if opted.","RTGS/NEFT mandate form details must be accurate and complete.","Terms and conditions for RTGS/NEFT payments apply as stated."],"title":"CLAIM FORM FOR ALL RISK INSURANCE","submit":{"to":"Assigned Claims Manager (CSM) or Surveyor","how":"Submit claim form and documents to assigned CSM/Surveyor","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation:","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":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"Describe the type of loss or damage.","type":"text","label":"Nature of loss/ damage.","options":[],"required":null,"pdf_field":""},{"help":"Describe the damaged property in detail.","type":"text","label":"Details of damaged property","options":[],"required":null,"pdf_field":""},{"help":"Provide exact location of the loss.","type":"text","label":"Place & address where the loss took place.","options":[],"required":null,"pdf_field":""},{"help":"Provide date, time and place last seen.","type":"text","label":"When and where was the missing property last seen?","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of discovery.","type":"date","label":"Date and time when loss was first discovered.","options":[],"required":null,"pdf_field":""},{"help":"Explain how the loss or damage occurred.","type":"text","label":"State the circumstances of the loss or damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated monetary value.","type":"amount","label":"Estimated value of items lost or Damaged","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of police report.","type":"date","label":"Date and time of reporting the loss to Police Station.","options":[],"required":null,"pdf_field":""},{"help":"Attach copy of FIR.","type":"attachment","label":"(Please furnish copy of FIR)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Police and Ownership Details","fields":[{"help":"Provide police station details.","type":"text","label":"Name and address of the Police Station.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you the sole owner of the property?","options":["Yes","No"],"required":null,"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":null,"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":null,"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. If Yes, provide details of relationship and position held by PEP.","type":"choice","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 applicable.","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 Claim Clause","fields":[{"help":"Date of signing.","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing.","type":"text","label":"Place:","options":[],"required":null,"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":null,"pdf_field":""},{"help":"Enter name as per bank records.","type":"text","label":"Payee Name (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number.","type":"text","label":"Payee Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Select account type.","type":"choice","label":"Type of Account:","options":["Savings","Current","Others (specify)"],"required":true,"pdf_field":""},{"help":"Enter bank name.","type":"text","label":"Name of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name.","type":"text","label":"Branch Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch address.","type":"text","label":"Address of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code.","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code.","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number.","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":true,"pdf_field":""},{"help":"Sign here.","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"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":"All Risk Insurance claims","attachments":["Copy of FIR","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 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 information given in this claim form is true, correct and complete.","All persons having interest in the property are disclosed as per proposal or policy endorsement.","No material information relevant to claim processing has been withheld.","False or fraudulent statements or suppression of material information will void the policy and claim rights.","Receipt of claim form or documents does not constitute admission of claim liability by the company.","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes 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/487-claim-form-for-all-risk-insurance"}