{"id":489,"title":"CLAIM FORM FOR BURGLARY 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-burglary-insurance-retail.pdf","sha256":"5bd5c0b4a35d3044721625e0d6138ac9dc6d2c59e389944b79a781a9f8e1efce","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to notify and claim for physical loss or damage due to burglary under their insurance policy.","notes":["Attach original police complaint copy","Submit all relevant documents as listed","Use correct and complete information to avoid claim rejection","Electronic Fund Transfer details are mandatory if opting for EFT payment","Terms and conditions for RTGS/NEFT payments apply as stated in the form"],"title":"CLAIM FORM FOR BURGLARY INSURANCE Notification of Physical Loss or Damage","submit":{"to":"Assigned Claims Service Manager (CSM) or Surveyor","how":"Submit documents to assigned CSM/Surveyor as per claim process","address":""},"purpose":"claim","sections":[{"title":"Details of Insured and Loss","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured person or entity","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Phone number to contact insured","type":"phone","label":"Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"Provide full address and occupancy details of the premises where loss happened","type":"text","label":"State the address of premises at which the loss occurred. How was the said premises occupied?","options":[],"required":null,"pdf_field":""},{"help":"Date and time when loss occurred","type":"date","label":"Date and time of losses","options":[],"required":null,"pdf_field":""},{"help":"Date/time loss was discovered and name of person who discovered it","type":"text","label":"When discovered and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Describe how entry or exit was affected during the loss","type":"text","label":"How was entry to / exit from the premises affected?","options":[],"required":null,"pdf_field":""},{"help":"Specify the affected area of the premises","type":"text","label":"Which portion of the premises was affected by the entry or exit?","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss event and list stolen or damaged items","type":"text","label":"Give brief detail of how exactly the loss occurred. (Specify the articles stolen and property damaged)","options":[],"required":null,"pdf_field":""},{"help":"Provide police complaint details and attach copy","type":"text","label":"Has a complaint been lodged with the police? If so, by whom and when and at which Police Station? (Attach a copy of the Police complaint.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Were the premises occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time premises were last occupied if not occupied at loss time","type":"date","label":"If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Loss Details","fields":[{"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":"","type":"yes-no","label":"Is the Insured the sole owner of (a) The property lost or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured responsible for repairs to the premises?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Total value of all property at premises when loss occurred","type":"amount","label":"State the total value of property upon the premises at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Insurance amount and insurer names for the property","type":"text","label":"State the amount of the insurance upon such property and name(s) of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Details of any other insurance covering this loss","type":"text","label":"Is there any other Insurance against the present loss under any other policy? If so, give full particulars","options":[],"required":null,"pdf_field":""},{"help":"Additional relevant information for claim processing","type":"text","label":"Any other information relevant to processing of claim.","options":[],"required":false,"pdf_field":""},{"help":"Select if any applicant is a Politically Exposed Person or related","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","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answer to previous is Yes","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":"Claim Clause and Settlement","fields":[{"help":"Date of signing the form","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing the form","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","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 to provide bank details for payment","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Payee Name (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"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":"Bank name","type":"text","label":"Name of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name :","options":[],"required":true,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"IFSC code for electronic transfer","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"MICR code of the bank branch","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"PAN of the payee","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":true,"pdf_field":""},{"help":"Signature for EFT mandate","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":"Burglary insurance claims","attachments":["Copy of the Police complaint","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 items to be repaired or reinstated","Documents substantiating the quantum & value of items under claim not to be 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 endorsements","No material information relevant to claim processing has been withheld","False or fraudulent statements or concealment of information will void the policy and claims","Receipt of claim form or documents does not constitute admission of liability by the company","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC"],"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/489-claim-form-for-burglary-insurance-notification-of-physical-loss-or-damage"}