{"id":496,"title":"CLAIM FORM DIRECTORS AND OFFICERS LIABILITY 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/directors-and-officers-liability-commercial.pdf","sha256":"a3c824d32a9b5f21a00434b2800f099cf9a91a65845b9021d4a790c914b8f56c","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for notifying and claiming under Directors and Officers Liability Insurance. It is filled by the insured party making the claim.","notes":["The insured must give information and cooperation as reasonably required by the insurer","No settlement, costs, contractual obligations or admissions of liability can be made without the insurer's prior written consent","The intimation is without prejudice and insurer's rights are reserved"],"title":"CLAIM FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Attach separate pages if required","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"","type":"text","label":"Chronology of Events","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"The nature of the alleged damage,","options":[],"required":null,"pdf_field":""},{"help":"List all claimants and defendants","type":"text","label":"The names of the claimants Defendants","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Persons as defined on the form","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":"Describe relationship and position held by the PEP","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":"Status of proceedings as on date","fields":[{"help":"","type":"text","label":"Status of proceedings as on date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"","type":"yes-no","label":"Is there any other insurance that may be applicable to this notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of Cover","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of policy period","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Directors and Officers Liability Insurance","attachments":["Copy of the legal notice/written intimation received by the Insured","Any legal opinion considered by the Insured","Copy of the complete correspondence till date"],"declarations":["The information furnished in this Claim Intimation Form is true, correct and complete to the best of the insured's knowledge and belief","If any untrue or false statement is made or material facts are concealed, the right to claim under the policy shall be forfeited","Consent is given to the insurer to seek necessary information/documents from any third party who has made the claim against the insured","Consent is given to the insurer to verify and obtain identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes"],"dropped_labels":5},"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/496-claim-form-directors-and-officers-liability-insurance"}