{"id":505,"title":"Surety Insurance Unconditional- Claim Form","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-surety-insurance-unconditional8c0007ff45fd68ff8a0df0055fb0c234.pdf","sha256":"6cd65f19590b792956b9ea297cc58586bcc323ed86408f6a7f693d08442a4565","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for claiming under a Surety Insurance policy and is to be completed and signed by the authorized person of the insured or claimant.","notes":["Please read the claim form fully before answering.","All questions must be answered as fully as possible; use additional sheets if necessary.","Attach copies of relevant documentation.","Issuance of this form is not proof of admissibility of liability."],"title":"Surety Insurance Unconditional- Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claim Details and Claimant Information","fields":[{"help":"","type":"date","label":"Date of Claim","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ICICI Lombard Policy No","options":[],"required":null,"pdf_field":""},{"help":"Name of the Creditors/ Beneficiary/ Claimant","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of the Creditors/ Beneficiary/ Claimant","type":"text","label":"Complete Address","options":[],"required":null,"pdf_field":""},{"help":"Name of the authorized person for the claimant","type":"text","label":"Authorized person: Name","options":[],"required":null,"pdf_field":""},{"help":"Designation of the authorized person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Contact number of the authorized person","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"Email ID of the authorized person","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed under the Surety Bond","type":"amount","label":"Amount of Surety Bond claimed","options":[],"required":null,"pdf_field":""},{"help":"Explain reasons for revoking the Surety Bond with supporting details","type":"text","label":"Reasons for Revoking Surety Bond, along with supporting information","options":[],"required":null,"pdf_field":""},{"help":"Name of the Insured/ Principal Debtor/ Contractor/ Concessionaire","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of the Insured/ Principal Debtor/ Contractor/ Concessionaire","type":"text","label":"Complete Address","options":[],"required":null,"pdf_field":""},{"help":"Name of the contact person for the insured","type":"text","label":"Contact person: Name","options":[],"required":null,"pdf_field":""},{"help":"Designation of the contact person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Contact number of the contact person","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"Email ID of the contact person","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Name of the project related to the Surety Bond","type":"text","label":"Project Name","options":[],"required":null,"pdf_field":""},{"help":"Value of the project","type":"amount","label":"Project Value","options":[],"required":null,"pdf_field":""},{"help":"Value of the Surety Bond","type":"amount","label":"Bond Value","options":[],"required":null,"pdf_field":""}],"filled_by":"authorized person of Insured/ Claimant"},{"title":"Bank Account Details of Creditors/ Beneficiary/ Claimant for claim payment","fields":[{"help":"Name as per bank records","type":"text","label":"Name of the bank account holder","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Bank Account No","options":[],"required":null,"pdf_field":""},{"help":"Bank name and branch","type":"text","label":"Name of Bank & Branch","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Type of bank account (e.g. Savings, Current)","type":"text","label":"Account Type","options":[],"required":null,"pdf_field":""},{"help":"Tick the proof document attached for bank details","type":"checkbox","label":"Attachments in support of Bank Details (Please tick the type of proof submitted)","options":["Cancelled Cheque","Bank Passbook Copy"],"required":null,"pdf_field":""}],"filled_by":"authorized person of Insured/ Claimant"},{"title":"Annexures to be attached","fields":[{"help":"Indicate if this document is attached","type":"choice","label":"Written demand from the Creditor to the Company for invocation of the Surety Bond mentioning the amount and the condition/s breached by the Principal Debtor. The said demand must also (wherever applicable) record and attach copy that an opportunity given to the Principal Debtor to rectify the alleged Default, as per the terms of the underlying Contract, was provided but the said alleged Default has not been cured by the Principal Debtor","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if this document is attached","type":"choice","label":"Any other necessary documentation required by the Company, as deemed necessary to establish the Principal Debtor’s liability and/or the quantum of the claim payable under this Surety Bond","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declarations and Signature","fields":[{"help":"Signature and company seal of the claimant","type":"signature","label":"Claimant Signature & Company Seal","options":[],"required":null,"pdf_field":""},{"help":"Name of the authorized signatory","type":"text","label":"Authorized Signatory Name","options":[],"required":null,"pdf_field":""},{"help":"Designation of the authorized signatory","type":"text","label":"Authorized Signatory Designation","options":[],"required":null,"pdf_field":""},{"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":""}],"filled_by":"authorized person of Insured/ Claimant"}],"deadlines":[],"applies_to":"Surety Insurance claims","attachments":["Written demand from the Creditor to the Company for invocation of the Surety Bond mentioning the amount and the condition/s breached by the Principal Debtor","Any other necessary documentation required by the Company to establish liability and/or quantum of claim","Cancelled Cheque or Bank Passbook Copy as proof of bank details"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property related to the claim are disclosed as per the proposal or policy endorsements.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or undisclosed.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of this claim form or documents does not mean the claim is admitted; the company may require further information or reject the claim.","Consent is given to the company to verify identity/address proofs through Central KYC Registry, UIDAI or other modes for KYC purposes."],"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/505-surety-insurance-unconditional-claim-form"}