{"id":488,"title":"FINANCIAL SERVICES /INSTITUTIONS PROFESSIONAL INDEMNITY 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_fipi-commercial8c0007ff45fd68ff8a0df0055faefc6a.pdf","sha256":"7644ecd6112dce41a145939e6163cf772cef5d935f1590950b7e51805da723e7","pages":9,"collected":"2026-10-20","instructions":{"about":"This form is for reporting and claiming under the Financial Services/Institutions Professional Indemnity Insurance policy. It is filled by the insured party who holds the policy and is reporting a claim or incident.","notes":["The issue of this form is not to be taken as an admission of liability.","Completion and return of this form should not be delayed if any particulars cannot be immediately given; they may be forwarded later.","Attach copies of all relevant documents as specified.","Insured shall not enter into compromise/settlement without written permission of the Company."],"title":"FINANCIAL SERVICES /INSTITUTIONS PROFESSIONAL INDEMNITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road Malad (W), Mumbai - 400 064"},"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/Profession of Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid contact number","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide claimant's contact number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Date when claim was made","type":"date","label":"Date of claim","options":[],"required":null,"pdf_field":""},{"help":"Claim amount in currency","type":"amount","label":"Amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Specify claimant's capacity","type":"text","label":"Capacity in which the claimant is making the claim i.e. as client, third party, any other)","options":[],"required":null,"pdf_field":""},{"help":"Describe the allegation; attach claim notice copy","type":"text","label":"Allegation in the claim ( Please attach a copy of the claim notice )","options":[],"required":null,"pdf_field":""},{"help":"Provide details if claim is anticipated","type":"text","label":"In case you anticipate a claim, please specify","options":[],"required":null,"pdf_field":""},{"help":"Explain reason and nature of error/omission","type":"text","label":"The reason why you anticipate such a claim, Nature of error or omission if any on your part","options":[],"required":null,"pdf_field":""},{"help":"Specify source and expected time of claim","type":"text","label":"From whom and when you anticipate such a claim","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Details","fields":[{"help":"Describe professional service type","type":"text","label":"Mention the type of professional service provided to the Claimant / prospective claimant","options":[],"required":null,"pdf_field":""},{"help":"Date service was provided","type":"date","label":"When was the service provided to Claimant / prospective claimant","options":[],"required":null,"pdf_field":""},{"help":"Provide date and manner of first knowledge","type":"text","label":"When and how did you first come to know of the error/omission","options":[],"required":null,"pdf_field":""},{"help":"Provide location address","type":"text","label":"Address of the location/construction site where the error/negligence has occurred","options":[],"required":null,"pdf_field":""},{"help":"Describe incident briefly","type":"text","label":"Brief description of the incident which can lead to claim","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"Give particulars of any other insurance, if any in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","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 relationship and position details if yes","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":null,"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","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Alleged Claim","fields":[{"help":"Date and time of alleged error/omission","type":"date","label":"Alleged Date & Time","options":[],"required":null,"pdf_field":""},{"help":"Describe error/omission/negligence","type":"text","label":"Error/Omission/negligence of","options":[],"required":null,"pdf_field":""},{"help":"Name of alleged person","type":"text","label":"Name of the person who has been alleged for Error/Omission","options":[],"required":null,"pdf_field":""},{"help":"Designation of alleged person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Qualification of alleged person","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Describe the event briefly","type":"text","label":"Brief description of the event","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claimant","fields":[{"help":"Provide claimant details; attach extra sheet if needed","type":"text","label":"Give name/es, address/es occupation/s of Claimant (Attach separate sheet, if space not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"Describe injury/damage/loss; attach extra sheet if needed","type":"text","label":"Details of Injury/death/damage/loss to the claimant (Attach separate sheet, if space not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"Number of victims involved","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Specify claimant's capacity; attach complaint/notice","type":"text","label":"Mention the capacity under which the claim is being made by the claimant (Attach the written complaint/notice given by the claimant)","options":[],"required":null,"pdf_field":""},{"help":"Provide property damage details if applicable","type":"text","label":"Has the accident caused damage to property? 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":"Compensation amount claimed","type":"amount","label":"Mention the amount of compensation claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Compromise Details","fields":[{"help":"State if liable and reasons","type":"text","label":"Do you agree that you are liable for the incident. Give reasons","options":[],"required":null,"pdf_field":""},{"help":"Explain reasons and strategy for compromise/settlement","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game-plans/strategy for the same.","options":[],"required":null,"pdf_field":""},{"help":"Current status of negotiations","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"Proposed liability amount","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"Select yes or no","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the incident ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide copies of notices/summons if yes","type":"text","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":[],"required":null,"pdf_field":""},{"help":"Provide copies of court orders if yes","type":"text","label":"Has the court passed any interim or final order? If yes, please provide copies of the same","options":[],"required":null,"pdf_field":""},{"help":"Attach copies of all court documents submitted","type":"attachment","label":"Also provide copies of all the documents that have been submitted to the Court either by you or the Claimants.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Legal Advice","fields":[{"help":"Describe proposed response","type":"text","label":"The Insured’s proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"Provide legal advisor details and opinion if applicable","type":"text","label":"Does the insured propose to/has already availed of, any legal advise. If Yes, details of the lawyer/law firm together with their opinion","options":[],"required":null,"pdf_field":""},{"help":"Describe proposed steps if no legal advice taken","type":"text","label":"If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":null,"pdf_field":""},{"help":"Estimate legal/defense costs","type":"amount","label":"Estimated Legal/Defence Cost/fees which will be incurred","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"Provide any other supporting evidence","type":"text","label":"Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if any","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Settlement Details","fields":[{"help":"Provide settlement amount and proof","type":"amount","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants? Please provide proof of the following (agreement, understanding, court order, court award etc).","options":[],"required":null,"pdf_field":""},{"help":"Provide court imposed liability amount and copy of award","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you? Please provide copy of the court award.","options":[],"required":null,"pdf_field":""},{"help":"Provide total defense costs incurred","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Signature (Claim Settlement)","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 here","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Financial Services /Institutions Professional Indemnity Insurance claims","attachments":["Copy of the claim notice","Written complaint/notice given by the claimant","Copies of court notices/summons if any","Copies of court orders if any","Copies of all documents submitted to the court","Proof of settlement (agreement, understanding, court order, court award etc)","Copy of court award"],"declarations":["The statements/information given in this form are true, correct and complete.","No material information relevant to the claim has been withheld or not disclosed.","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 constitute admission of liability by the Company.","Consent is given to the Company to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes."],"dropped_labels":1},"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/488-financial-services-institutions-professional-indemnity-insurance"}