{"id":501,"title":"CLAIM APPLICATION FORM FOR EMPLOYEE’S COMPENSATION 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-application-form-for-employee-s-compensation-insurance-commercial.pdf","sha256":"c0891892522b95fd7f043de90bd3fa2956b1f866ba56b257894306ac6ff70f30","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is for notifying ICICI Lombard General Insurance Company about an employee's compensation claim and seeking permission to settle the claim. It is filled by the insured employer or policyholder.","notes":["Do not delay returning this form even if some particulars are not immediately available; they may be sent later.","The insured shall not enter into settlement without prior written permission of the company.","Follow instructions carefully in the Statement of Wages section to avoid delays.","Attach original and relevant documents as required.","Use block letters where applicable."],"title":"CLAIM APPLICATION FORM FOR EMPLOYEE’S COMPENSATION 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":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Injured Person","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years and select sex","type":"text","label":"Age and sex","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Residential Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of occupation","fields":[{"help":"","type":"text","label":"What is the occupation in which the injured person is employed?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person engaged in this occupation when the accident occurred?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if previous answer is No","type":"text","label":"If not state fully the nature of the work he was doing at the time of the accident?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of employment","fields":[{"help":"","type":"yes-no","label":"Is the injured person in your direct employment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if previous answer is No","type":"text","label":"If not give name and address of Contractor?","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"When did the injured person enter your service?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Accident","fields":[{"help":"Provide both date and time","type":"date","label":"Date and time of accident.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of accident.","options":[],"required":null,"pdf_field":""},{"help":"Describe what happened","type":"text","label":"Give brief description of the accident?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the claimant at the time of accident in the course of employment. If yes, state details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person under the influence of alcohol or other intoxicant at the time of the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide details","type":"yes-no","label":"Was he guilty of any misconduct or disobedience to orders / rules, due to which incident occurred? If so, please give full particulars.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you satisfied that the injured person has met with a bona-fide accident of employment?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Injury","fields":[{"help":"Describe the injury","type":"text","label":"Give a brief description of injury?","options":[],"required":null,"pdf_field":""},{"help":"Attach doctor's certificate confirming disability percentage","type":"number","label":"What is the % of disability if any? Attach a certificate of doctor confirming disability?","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"What is the probable period of the disablement?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospital","fields":[{"help":"","type":"yes-no","label":"Has the injured person been removed to hospital or medically attended?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of admission in hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of discharge from hospital.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Return to Work","fields":[{"help":"","type":"yes-no","label":"Whether injured person has returned to work?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide date and number of days absent","type":"text","label":"If yes, then the date of return and no. of days of absence?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copies if Yes","type":"yes-no","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide date and time","type":"text","label":"Date and time of receipt of notice/summons from the authorities","options":[],"required":null,"pdf_field":""},{"help":"Describe current status and next hearing date","type":"text","label":"What is the present status of the proceedings? Also give the next date of hearing.","options":[],"required":null,"pdf_field":""},{"help":"Attach all relevant court documents","type":"attachment","label":"Provide copies of all the documents that have been submitted to the Court either by you or the employee/claimants, and copies of all the documents received with the notice from the court.","options":[],"required":null,"pdf_field":""},{"help":"Attach copies if Yes","type":"yes-no","label":"Has the court passed any interim or final order? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide date and attach copy if Yes","type":"yes-no","label":"Has the subject matter of the alleged claim/complaint been earlier reported to the Company by an Incident Reporting Form? If yes, please provide date of Incident Reporting Form, and append copy thereof","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if previous answer is No","type":"text","label":"If no, kindly submit a duly completed Incident Reporting Form / or set out here the Insured’s views/comments on the alleged incident which has resulted in the alleged claim or compliant arising.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"The Insured’s proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the insured propose to/has already availed of, any legal advise.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if previous answer is Yes","type":"text","label":"If Yes, details of the lawyer/law firm together with their opinion.","options":[],"required":null,"pdf_field":""},{"help":"Fill if previous answer is No","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":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"","type":"text","label":"Details of claims if any preferred by the affected party / claimant for the same loss from another source.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give name and address of witness if any?","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Person","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":"Fill only if previous answer is 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":"Declaration and Consent","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":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Statement of Wages","fields":[{"help":"Enter wages and allowances for each month as per instructions","type":"table","label":"Month, Wages, Bonus, Value of Free Quarters and Any Other Allowances and Total including all Allowances","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Were the above stated wages paid, or fallen due for payment, to the injured person?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person absent from work at any time, during the above stated period, for 14 or more consecutive days?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide absence details if applicable","type":"text","label":"If so, give the following particulars: Absent for days from to","options":[],"required":null,"pdf_field":""},{"help":"Date of employer signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Employer to sign here","type":"signature","label":"Signature of the Employer","options":[],"required":true,"pdf_field":""}],"filled_by":"employer"}],"deadlines":[],"applies_to":"Employee’s Compensation Insurance claims","attachments":["Certificate of doctor confirming disability","Copies of court notices/summons if any","Copies of court documents submitted or received","Copy of Incident Reporting Form if previously submitted"],"declarations":["The insured warrants the truth of all statements and understands that false or fraudulent statements will forfeit the claim and void the policy.","The insured consents to the company verifying identity and address proofs through Central KYC Registry, UIDAI or other modes.","Receipt of this form does not constitute approval for settlement; permission must be granted by the company."],"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/501-claim-application-form-for-employees-compensation-insurance"}